MANUAL OF DISEASES OF THE THEOAT AND NOSE THE SECOND VOLUME Of this work U in the press and will be publislied in a few montht. Il Kill include DISEASES OF THB (ESOPHAGUS, NASAL CAVITIES, AND NECK The foUowing is an abstract of the Contents .— CESOPHAGUS— CEsophagitis, Dilatation, Cancer, Non-Mahgnant Tumours, Nervous Dysphagia, Wounds, Foreign Bodies, Malformations, &c. &c. NOSE- Catarrh, Ozasna, Chronic Rhinitis, Epistaxis, Polypus, Adenoid Growths, Cancer, Syphilis, Nasal Calculi, Foreign Bodies in the Nasal Cavities, Malformations, &c. &o. NECK.— Scrofula, Lymphoma, Sarcoma, Goitre, Exophthalmic Bronchpctfe. Cysts, Aneurisms, &c. &c. ' ■ A MANUAL OF DISEASES OF THE THEOAT A'NB NOSE, DTOLUDING THE PHARYNX, LARYNX, TRACHEA, (ESOPHAGUS, NASAL CAVITLES, AND NECIC. MOEELL MACKENZIE, M.D. Lond., SENIOn PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THE THBOAT AND CHEST, LECTDBER ON DISEASES OF THE THROAT AT THE LONDON HOSPITAL MEDICAL COLLEGE, AND CORRESPONDINti MEMBER OF THE IMPERIAL ROYAL SOCIETY OF PHYSICIANS OF VIENNA. Vol. I. — Diseases of the Pharynx, Larynx, AND Trachea. LONDON : J. & A. CHUECHILL, NEW BURLINGTON STREET. 1880. \_All rights reserved.'] Digitized by the Internet Archive in 2015 https://archive.org/details/b21932177_0001 PREFACE. This work is based partly on the courses of lectures which I have annually delivered at the London Hospital Medical College during the last twelve years, and partly on my essay on " Diseases of the Larynx," to which the Jacksonian Prize was awarded by the Ptoyal College of Surgeons of England. Some of my lectures have appeared in the British Medical Journal, Lancet, and Medical Times and Gazette, but by far the larger portion of the matter contained in these pages is now published for the first time. The classification of disease is always attended with considerable difficulty, and at present no single system can be rigidly adhered to. For even accepting patho- logy as the basis, the tissues themselves are of so composite a character, and there are so many " organs within organs" in the human frame, that logical precision cannot be maintained, except by pedantic subdivisions, which would defeat the object of the arrangement. Again, whilst some throat affections are strictly circumscribed in their ravages, others attack different sections of the air-passages at the same time. Hence, although this work has been divided into certain primary sections, and as a rule each disease has been A * PREFACE, separately considered in its proper division; yet in some cases it has been found more convenient to depart from this plan, and to treat the morbid phe- nomena of contiguous parts together. The system of nomenclature issued by the Eoyal Col ege of Physicians has been adopted, with such modifications and additions as the consideration of a special class of diseases rendered necessary Eecords of cases have, as a rule, only been intro- duced where they were required for the illustration of a diacult subject, or where the cases themselves were exceptionally rare. The views which I entertain as regards the use of mercury in syi^hilis wHl probably meet with some opposition, but having followed Professor Sigmund's practice in Vienna in 1859 and 1860, I became well acquainted with his views at an early period of my medical career, and a somewhat extensive experience in dealmg with the constitutional phenomena of syphilis has smce convinced me of the truth of the fundamental views entertained by the eminent Viennese Professor VIZ.:— (1) That specific anti-syi^hilitic treatment is only required when serious constitutional symptoms are present; (2) that specific treatment in the early stages does not ward off the later manifesta- tions of the affection; (3) that local treatment analeptic remedies, and hygienic measures are of the utmost importance ; (4) that the disease itself, except under unfavourable circumstances, tends towards spontaneous cure; and (5) that the development of serious pathological changes depends on conditions inherent in the patient himself. These views ha^^e been sustained by Professor Sigmund with all his old energy in the recent edition of his well-known " Vorlesungen iiber neuere Behandlungsweisen der PREFACK. vii SyphHis." It wiU, I hope, be understood that whilst employing iodide of potassium more frequently, I nevertheless consider mercury a valuable, and in some cases an indispensable, remedy in syphilis. Whilst placing the results of my own experience before the' profession, I have endeavoured to do full justice to the many physicians, both ancient and modern, who have elucidated the class of affections herein discussed ; and if, in any case,. I have failed to aclvnowledge the labours of others, I trust that the error may be looked upon as accidental. I am indebted to many distinguished authors for Idndly forwarding me their valuable works and new editions, and I much regret that I was only able to make use of some of them for a few casual references, in consequence of their not having reached me until the greater part of this volume was already in type. This remark especially applies to the second edition of Dr. Solis Cohen's excellent work on " Diseases of the Throat and Nasal Passages," and to the second (German) edition of Prof. Ziemssen's able contribution on the " Krankheiten des Kehlkopfes " to his own Encyclopaedia ; it applies also to Dr. Max Schiiller's exhaustive article in the "Deutsche Chirurgie," entitled " Tracheotomie, Laryngotomie, und Exstirpation des Kehlkopfes," and to Prof. Stoerk's compxehensive treatise in the same series on the "Krankheiten des Kehlkopfes, der ISTase, und des Eachens." For the reason stated above I have also been obliged to forego the satisfaction of even referring to many other smaller works, to which I hope to do justice on a future occasion. Incomplete as tlie work is in many respects, yet, owing to my numerous professional engagements, I could not have collected the materials on which it is viii PREFAOB. founded had it not been for the assistance I have received from many friends. It would be difficult to assign to each the due amount of my obligations, and I must therefore content myself by thanking them collectively. There are a few, however, whose names cannot be altogether omitted. Thus I am especially indebted to my colleague, Dr. Semon, who has prepared a German translation of this work (to appear simultaneously with the English edition), for many important suggestions and much keen criticism; I have to thank my former assistant, Dr. Gordon Holmes, for valuable aid in matters of historical research, more particularly in connection with those authors whose observations are recorded in the classical languages ; and I am very grateful to Mr. Mark Hovell, Eesident Medical Officer and Eegistrar to the Hospital for Diseases of the Throat and Chest, for preparing a detailed index. M. M. 19, Hahley Stebet, London, May, 1R80. CONTENTS. SECTION I.— THE PHARYNX. Anatomy of the Pharynx; The Examination of the Pharynx ; Pharyngeal Instruments; Diseases of the Pharynx: Catarrh of the Pharynx; Uvulitis; Retro-pharyngeal Abscess ; Relaxed Throat and Uvula ; Ulcerated Throat ; Granular Phaiyngitis ; Putrid Sore Throat ; Hei-pes of the Phaiynx; Rheumatic Sore Throat; Gouty Sore Thi-oat; TonsiUitis; Enlarged TonsUs; Foreign Bodies in the Tonsils ; Parasites in the Tonsils ; Dilatation of the Pha- rynx; Cancer of the Pharynx; Cancer of the Tonsils; Non-malignant Tumours of the Pharynx ; Syphilis of the Pharynx ; Phthisis of the Pharynx ; Traumatic Pharyn- gitis ; Anginte caused by Poisonous Drugs ; Wounds of the Pharynx ; Foreign Bodies in the Pharynx ; Neuroses of the Pharynx : Neuroses of Sensation ; Neuroses of Motion ; Aphthse ; Diphtheria ; Laryngo-Tracheal Diph- theria, formerly called Croup; Nasal Diphtheria; The Throat Affections of the Eruptive Fevers : Scarlet Fever ; Measles ; SmaH-Pox ; The Throat AfBectious of Typhoid Fever ; Typhus ; Intermittent Fever ; Erysipelas of the Pharynx and Larynx SECTION II.— THE LARYNX. Anatomy of the Larynx ; The Laiyngoscope and its Ac- cessory Apparatus ; Laryngoscopy ; Auto-Laryngoseopy ; Infra-glottic Laryngoscopy ; The Laryngeal Image ; Laryngeal Instruments ; Dilators of the Larynx ; Acute Catari'hal Laryngitis ; (Edematoiis Laryngitis ; Traumatic Laryngitis ; Abscess of the' Larynx ; Clu-onic Laryn- giti.s ; Chronic Glandiilar Laryngitis ; Phlebectasis X CONTENTS. Laiyngea ; Trachoma of the Vocal Cords ; Sub-glottic Uu-onic Laryngitis ; Chi-onic (Edema of the Larynx • Non-MaHgnant Tumours of the Larynx; Malignant Tumoui-8 of the Larynx: Cancer of the Larynx; becondary Cancer; Sarcomata; Syphilis of the Larynx • Laryngeal Phthisis ; Perichondritis of the Larynx and Necrosis of the CartUages ; Lupus of the Larynx ; Cases iUustrating Lupus of the Larynx ; Leprosy of the Larynx ; Cases illustrating Leprosy of the Larynx ; Fractui-es and Dislocations of the Larynx ; Fractm-e and Dislocation of the Hyoid Bone ; Wounds of the Larynx ; Bm-ns of the Larynx ; Foreign Bodies hi the Larynx ; Case of Impac- tion of a Lamella of Bone Transversely in the Ventricles ; Nervo-Muscular and Sensory Affections of the Larynx \ Anaesthesia of the Larynx ; Cases of Antesthesia of the Larynx after Diphtheria; Hyper:esthesia, Partesthesia, and Neuralgia ; Laryngeal Paralysis from Disease or Injury of the Medulla Oblongata; Cases iUustrative of Paralyses from Disease of the Medulla Oblongata ; Laryn- geal Paralysis from Disease or Injmy of the Spinal Acces- sory Nerve ; Laryngeal Paralysis from Disease or Injury of the Pneumogastric Nerve; Laryngeal Paralysis from Disease or Injury of the Superior Laryngeal Nerve ; Case of Inflamed Cervical G-lands pressing on the Superior Laryngeal Nerves; Laryngeal Paralysis from Disease or Injury of the Recurrent Nerve ; Bilateral Paralysis ; Cases illustrating Complete and Partial Bilateral Paralysis of the Recm-rent Nerves ; Unilateral Paralysis ; Paralysis of Individual Laryngeal Muscles ; Paralysis of the Abductors of the Vocal Cords ; Cases illustrative of Bilateral Paraly- sis of the Abductors ; Paralysis of One Abductor ; Cases illustrating Paralysis of One Abductor ; Bilateral Pai-aly- sis of the Adductors of the Vocal Cords ; Paralysis of One Lateral Adductor; Cases iUustrating Paralysis of One Lateral Adductor ; Paralysis of the Central Adductor (Inter-Arytenoid Muscle) ; Paralysis of the External Ten- sors of the Vocal Cords (Crico-Thyi-oid Muscles) ; Cases illustrating Paralysis of the External Tensors; Paralysis of the Internal Tensors of the Vocal Cords (Tliyro- Arytenoidei Intemi) ; Mixed Paralyses ; Atrophy of the Vocal Cords ; Anchylosis of the Arytenoid Articulations ; Spasm of the Glottis ; Spasm of the Glottis in Adidts ; Nervous Laryngeal Cough ; Spasm of the Tensors of the Vocal Cords ; Chorea of the Larynx ; Malfonnations of the Larynx ......... 202" CONTENTS. xi SECTION III,— THE TRACHEA. Auatomy of the Trachea ; Sm-gical Anatomy of the Laryngo- Tracheal Region ; Tracheoscopy ; The Tracheal Image ; Ti-acheal Instriunents ; Tracheotomy Instruments ; Acces- sory Instruments used in connection with Tracheal Canulfe ; Acute Catarrhal Tracheitis ; Chronic Tracheitis ; Non-Malignant Tumours in the Ti'achea ; Short Abstracts of all the Cases of Tracheal Growths observed by the Author; Osseous Growths; Post-Tracheotomic Vegeta- tions ; Malignant Tumom-s of the Trachea : Cancer of the Trachea; Case of Cancer of the Trachea; Cancer from Contiguity; Sarcoma of the Trachea; SypliiUs of the Trachea; Stricture of the Trachea; Compression of the Trachea ; Tracheal Phthisis ; Wounds of the Trachea ; Bronchotomy, including Tracheotomy and (Crico-Thyroid) Laryngotomy ; Tracheotomy ; Lai7ngotomy (Crico-Thy- roid) ; Laryngo - Tracheotomy ; Thermo - Cautery in Laryugo-Tracheal Operations ; "Withdrawal of the Canula ; Tracheocele ; Foreign Bodies in the Trachea ; Malforma- tions of the Trachea APPENDIX. Special Formulte for Topical Remedies : Steam Inhalations ; Spray Inhalations ; Fuming Inhalations ; Gargles ; Lozen- ges ; Pigments ; Insufflations ; Nutritive Enema ; Metric Measurements compared with the English Inch . . 573 COEEIGENDA AND ADDENDA. ge 13, line 15 from bottom, /or "Metzler" read "Meltzer." , 90, line 6 from top, for " Lanceraus " read " Lancereaux." , 269, line 17 from top, add the figure " 2 " after Ziemssen. , 2r9, line 7 from bottom, for " Sanne " read " Sestier." , 292, foot-note, for " Traite de Pathologie interne," vol. i. read " Virchow'rt Handbuch der speciellen Pathologie und Therapie." Abtheilung : "KranUheiten des Larynx und der Trachea," p. 492. , 293, foot-note 1, for "Traits de Pathologie," &c, read "Ziemsaen's Cyclo- ■ psedia" (Engl. Edit.), vol. iv. p. 217. , 295, line 16 from top, for " nine " read " seven." , 298, the second part of foot-note 8 refers to Gui-don Buck on page 299. , 300, to the last foot-note, ^/'e^x figure " 9." , 347, case No. 14, column 7, after the word " with," add " exception of." , 376, omit the word " and " at the end of Une 22. 376, transfer foot-note 1 to page 381, and prejix the figure " 2 " to it in place of " 1," adding also a figure " 2 " after Erankel, line 5 from bottom. 380, line 3 from bottom, after phthisis, add " in which there was laryngeal ulceration." 331, see above, page 378. 391, line 10 from top, for " 5 times " read " 4 times." 392, line 18 from top, oviit the words " ti'aumatic cases." 427, line 28 from bottom, for " left " read " right." 429, line 18 from bottom, for " fifteen " read " five." 431, line 14 from bottom, for " 1862 '' read " 1864." 439, in place of foot-note 3, read " Deutsches Archiv f . Win. Jledicin, 1867, ii. S. 550." 465, line 13 from top,/o;- "tonic" read "toxic." 468, line 8 from bottom, for " Olliver " read '• Oliver-." 481, line 5 from bottom, for " Miller " read " Millar." 486, line 13 from bottom, for " Steiner " read " Stefifen." 495, line 15 from top, omit " Previously," and in next line,/«j- "had " read "has." A MANUAL OF DISEASES OE TEE THEOAT AND NOSE. SECTION I.— THE PHARYNX. K>t AI^ATOMY OF THE PHAEYITX. The pharynx is that portion of the alimentary tube which corresponds in extent to the interval between the basilar process of the occipital bone above and the interval between the fourth and fifth cervical vertebrte below. It is continuous below with the cesophagus and larynx, in front with the nasal and oral cavities, and above with the ear. It may be described as an irregularly iiattened cylinder, wider above than below, and slightly concave anteriorly, applied to the anterior surface of the vertebrse. Its roof, which Ues immedi- ately below the skull, is quadiilateral, with rounded edges. It is concave in an antero-posterior direction, directly continuous with its posterior wall, and ia form, may not inaptly be compared to the hood of a carriage. The pharynx is freely moveable over the cervical spine, and thus permits the various movements wliich take place in swallowing and respiration. It is in relation vdth the foUowing struc- tures : posteriorly, with the pre-vertebral muscles, which are covered by a strong aponeurosis, and from which it is separated by the retro- pharyngeal cellidar tissue ; laterally, with the carotids, the internal jug^ar veins, the eighth pair of nerves, the sympathetic nerve, and a chain of lymphatics and ganglia ; anteriorly, with the nasal f ossEe, soft palate, isthmus of the fauces, dorsum of tongue, and posterior aspect of the larynx. The maxim tun length of the pharynx in the adult is about five inches, and its superior transverse diameter about one inch and three-fifths. It is sUghtly wider opposite the comua of the hyoid bone, and opposite the cricoid cartilage it again becomes contracted. Its diameter, in an antero-posterior dii-ection, is about four-fifths of an inch superiorly. Below, its anterior and posterior surfaces are in contact in the centre. Its osseous relations are : superiorly, the basilar portion of the occipital, and the body of the sphenoid, bone, and the 80-caUed basilar fibre- cartilage ; anteriorly and above, the vomer in the mesial Hne ; laterally, the internal pterygoid plates of the sphenoid bone ; below, the horizontal plates of the palate bone ; and posteriorly, the anterior surface of the five upper cervical vertebrae, with their fibro-cartilages. B 2 DISEASES OP THE THEOAT AND NOSE. The pharynx consists essentially of a fibrous frame-work, lined by mucous membrane, and containing a complex nmscular layer, with blood-vessels and nerves. These elements will be described in the order they are met with in actual examination, a general idea of the inner aspect of the cavity being first given. For convenience of description, the pharynx may be regarded as consisting of a pharyngo-nasal, a pharyngo-oral, and a phai-yngo- laryngeal cavity. The former is concerned in resj)iration and in the modification of the tone of the voice ; the second and third, in both respiration and deglutition. The pharyngo-nasal space is contiauous anteriorly with the nasal cavities, and laterally communicates by means of the Eu.stachian tube with the middle ear. The upper wall or roof, ah-eady described, is rich in gland tissue, and shows numerous depressions and crypts. In some subjects there is a cavity of considerable depth situated pos- teriorly and in the centre of the roof, in which are found the openings of munerous follicles. This collection of follicles has been described by Luschka ^ as an aggregated acinous gland, and named the "pharyngeal tonsil," in contradistinction to the analogous glands in the fauces. This tonsil is about a centimetre in thickness, and is situated near the vault of the pharynx, between the orifices of the two Eustachian tubes. It is covered with the ciliated epitheUum found in this portion of the cavity. The gland is composed of foUi- cles more or less compactly united, and its surface is dotted by a number of small prominences — the openings of the glandulse. The pharyngeal tonsil is not enclosed within a proper capsule, the re- ticular connective tissue of the gland being continuous with that of the adjacent mucous membrane. According to Tortual- there is a deepish sinus at the anterior border of the roof, which he calls the sinus fauoimn superior ; it extends forwards from the semilunar fold of mucous membrane at the border of the posterior nares, externally and below the u^jper edge of the orifice of the Eustachian tube. The lateral walls of this cavity are limited superiorly by the openings of the Eustachian tubes and the recessus pharyugeus, or fossa of Eosenmiiller. The opening of the cartilaginous poi-tion of the Eustachian tube lies on the level of the posterior nares, and is about one-fifth of an inch below the base of the sknU, and about three inches and one-fifth from the anterior nares. The aperture is about two-fifths of an inch in its vertical, and about one-fifth in its transverse, diameter. That portion of it which appears in the pharynx is covered by mucous membrane, and is seen as a somewhat roimded elevation, with its convexity turned upwards and backwards ; fi-om its upper extremity a fold of mucous membrane extends to the border of the posterior nares, and from its posterior extremity another fold extends to the hinder surface of the velum pendulum palati. Between the orifice of the Eustachian tube and the posterior wall of the pharynx is a somewhat triangular shaped depression, covered with numerous glands, which is known as Rosenmiiller's fossa. The posterior wall of this portion of the pharynx is almost vertical, and lies in front of the pharyngeal fascia, the anterior arch of the atlas, and the body of the axis. Its mucous sm-face is smooth, and shows the openings of numerous acini. The anterior waU presents the 1 " Der Selilundkopf des Menschen." Tubingen, 1S68, p, 110. " Luschka : Op. cit. p. IS. ANATOMY OF THE PHARYNX. choante, separated hj the septum nariiun, and below them the posterior surface of the soft palate (vide p. 5). The pharyngo-oral cavity may be said to be limited superiorly by the level of the base of the uvula, and below by a plane passing- through the posterior extremities of the greater comua of the hyoid bone. The posterior siu-face of the uvula must be regarded as its incomplete anterior waU, the pillars of the fauces its lateral walls, and the base of the tongue, together with the folds of mucous membrane enclosing some muscular tissue, and known as the pharjoigo-epiglottic folds, its lower margin. The pharyngo-laiyngeal cavity occupies the position corresponding with the hyoid bone above and the inferior border of the cricoid car- tilage below. On its anterior sui-face, running obliquely downwards and sUghtly forwards, is the upper portion of the glosso- epiglottic fold on each side ; in the middle, is the epiglottis ; whilst the lower border of the cricoid cartilage may be regarded as its inferior limit. The posterior wall of this portion of the j)harynx is channelled out, and not flat as in the upper regions. Its anterior wall is wanting centrally, owing to the opening of the larynx. Laterally, the anterior wall of this portion of the pharynx presents a fossa on each side, the pharyngo -laryngeal sinus, which is about half an inch in its antero- posterior diameter and somewhat broader laterally. The pharyngeal walls average about one -tenth of an inch in thick- ness, and are foi-med of mucoiis membrane and giands, muscles, fibrous tissue, blood-vessels, lymphatics, and nerves. The mucous membrane is applied to the entire internal surface of the pharynx, and is continuous with all the openings into it ; it is sKghtly adherent to the imderlying tissues in the upper portion, but below, in the laryngeal region, it becomes very lax. The structure of the mucous membrane is partly fibrous tissue and partly connective, varying with its position, in the greater part of the pharyngo-nasal cavity. Lower down it is denser than above, and contains an abundance of glandulas. The epithelium in the phaiyngo -nasal cavity, the surface of which is of a pale rose colour, is cylindrical and ciliated, whilst in the pharyngo-oral region and below it is tesselated, and somewhat redder. The glands are of two kinds, conglomerate and follicular. In the pharyngo-nasal cavity the former are most abundant, particularly at the posterior border of the Eustachian tubes and on the phaiyngeal surface of the velum pendulum palati, where they are clustered to- gether. They are more sparsely distributed lower down. The fol- licular glands are found in the pharyngo-oral cavity, and in the roof of the phaiyngo -nasal cavity they are collected together and form "Luschka's tonsil " — already described. The fibrous structvire of the phaiynx forms a complete investment, and serves to maintain its fonn. It is very tough and strong, and has the fibres of the several muscles attached to it. It is attached superiorly and centrally to the basilar process of the occipital bone through the intervention of the cranio-pharyngeal ligament, and laterally to the petrous portions of the temporal bones, hanging sus- pended as it were from these points. Its internal suiiace is covered by the pharyngeal mucous membrane, whilst its external siu-face sup- ports the muscles of the pharynx. Below it becomes continuous with the cellular tissue of the oesophagus. Laterally, it is attached to the postenor border of the internal pterygoid plate of the sphenoid bone 4 DISEASES OF THE THROAT AND NOSE. to the pteiygo-maxillaiy ligament, the posterior portion of the mylo- hyoid ridg'e, the stylo-hyoid ligament, the comua of the hyoid bone, the thyi'o-hyoid membrane, and the posterior border of the thyi-oid, and the external siu-face of the cricoid, cartUage. The muscles of the pharynx consist of the three fiairs of constric- tors : the superior, middle, and inferior, wliich are an-anged in layers, and the stylo-pharyngei. The superior constrictors are flat quadrilateral muscles, the fibres of which are j)araUel to each other and directed horizontally. Their fixed insertion is to the lower portion of the internal pterygoid plate, the aponetu'osis of the soft palate, the i^terygo-maxiUai-y ligament, the posterior portion of the mylo-hyoid ridge, and slightly to the side of the tongue. Their moveable attachment is to the median raphe, where some of the fibres of the muscles interlace. The muscular fibres from the internal pteiygoid plate pass obliquely upwards to the median raphe at the base of the skull, forming a kind of festoon on either side of the middle Une ; the interspace is filled in by the pharyngeal aponem'osis and the mucous membrane (sinus of Morgagni). The middle constrictors lie in a plane posterior to the superior constric- tors, their fixed attachments being to the greater and lesser comua of the hyoid bone ; from these the fibres pass backwards in the shape of a fan, the superior ones passing upwards and inwards and covering the superior constrictor, the middle passing 'transversely, and the in- ferior downwards and inwards. They are ultimately partly inserted in the median raphe, and partly into the pharyngeal aponeui-osis — interlacing with each other. The inferior constrictors he in a plane posterior to the middle, and have as their fixed attachments, ante- riorly, the posterior border of the thyroid cartilage and the triangular surface on its outer wall, and the sides of the cricoid cartilage ; from these points the fibres pass backwards, the inferior, horizontally, and the superior, upwards and inwards. In the middle line the fibres are inserted into the pharyngeal aponeurosis, interlacing with one an- other, and vidth the inferior fibres of the middle constrictor. The stylo-pharyngei are long dehcate muscles arising from the bases of the styloid processes, and passing downwards, forwards, and in- wards ; the fibres expand and become inserted into the posterior border of the thyroid cartilage. At first this muscle is applied to the outer surfaces of the superior constrictor, but passing between the inner surface of the middle constrictor and the pharyngeal aponeu- rosis, it spreads out before it is inserted. These muscles are covered on their outer surfaces by the external fascia, which ia the lower two- thirds of the pharynx is derived from the deep cervical, and at the upper third from the bucco-pharyngeal, fascia ; whilst uitemally the fascia applied to them is the cephalo-pharyngeal, which is attached to the fibro- cartilage at the base of the skull. The arteries are : the ascending pharyngeal from the external carotid, which supplies the chief portion of the region and the Eustachian tube ; and anteriorly and laterally, behind and above the openings of the choante, some terminal twigs of the internal maxillary, the vidian, and spheno-palatine, which inosculate freely mth each other. The veins are collected iato a dense plexus in the deeper layers, and terminate in the internal jugular. The lymphatics form a net- work in the mucous membrane, and also in the muscidar structures, and terminate in glands situated at the base of the skull and near the greater comua of the hyoid bone. (Luschka.) ANATOMY OP THE PHARYNX. 5 The nerves are derived from the second division of the fifth, which suppUes the roof and orifice of the Eustachian tube, and from some i^o-s of the thii-d division, wliich, however, more particularly pass to the°soft palate. The glosso-pharyngeal nerve suppUes the stylo- pharyno-eus, the superior and middle constrictors, and the mucous membrane. The pharyngeal branches of the vagus, and glosso- phai-yngeus, and the spinal accessory, communicate and supply the upper and middle constrictors and the mucous membrane (Hyi-tl and Rudinger), whilst the superior laryngeal supplies the superior con- strictor. The sympathetic nerves are derived from the superior cervical and middle cervical ganglia. THE SOFT PALATE. The soft palate is a moveable cm-taiu continued backwards from the hard palate. It has two surfaces of mucous membrane, a pos- terior, contiauous with that of the nasal cavity, and an anterior, continuous with the lining membrane of the mouth. Between these mucous sm-faces is a stratum of muscular tissue. The soft palate (or velum pendulum palati) has the uvula in the centre, and laterally the pillars of the fauces, enclosuig the tonsil. Its direction is ob- liquely backwards and downwards, as regards the hard palate. It is variable in thickness, averaging from one-fifth of an_ inch to about half an inch; its depth varies from an inch to an inch and a-half , and from its crescentic shape it is deeper in the centre than at the sides. Between the pillars of the fauces laterally, the margin of the velum above, and the root of the tongue below, is an opening, capable of many and varied movements— the isthmus of the fauces. The anterior surface of the soft palate, which forms a portion of the mouth, presents on each side a sharp-edged free margin, spring- ing from the base of the uvula, and curving downwards to the tongue, constitutrag the anterior pillar of the fauces. The mucous membrane on this anterior aspect has a smooth sm-face, and con- tains a stratum of acini closely packed together and contiauous with those of the hard palate. In its mesial line is a vertical raphe— the iudication of the fusion of the sides during embryonic life. Its posterior sui-face constitutes a portion of the anterior wall of the pharynx, and is foi-med also by two sickle -shaped processes or folds, whose margins diverge from the uvula as on the anterior surface, but they are thicker and their edges more rounded. Their upper extremities commence at the base of the uvula, and forming smaller arches than those on the anterior surface, pass back- wards and dovmwards, becoming flatter as they descend, and losing themselves in the lateral walls of the pharynx. The mucous mem- brane is thickly studded with glands, which form a Continuous layer (solitary follicles). The epithelium is of the squamous variety, ex- ceptiug near the orifices of the Eustachian tubes, where it is ciliated. The uvula hangs from the centre of the soft palate, as a conical process about a quarter of an inch in length, having the two crescentic folds of the margin of the velum on either side. It is composed of mucous membrane very rich in glands, and contains the azygos uvulfe muscles. The tonsils lie between the pillars of the fauces, in a sort of niche, bounded internally by the base of the tongue. They are oval glandular masses, generally about as large as a hazel nut. They are follicular in structure, and, when of normal size, can bo just seen 6 DISEASES OP THE THROAT AND NOSE. when the mouth is wide open, projecting into the isthmus faueium. On the iaternal siu-f ace are a number of mucous crypts, which open by from twelve to sixteen ducts, of varying size, and give the sui-face of the tonsils the appearance of abnond nuts. In the spaces between the crypts, and enclosed iu the connective tissue, are a quantity of lymphatic glandulee. The tonsil is ia relation externally with the internal pterygoid muscle, and coiTesponds Avith the angle of the jaw, or more accm-ately, the centre of the tonsil corresponds with the posterior alveolar foramen. Posteriorly, are the internal and external carotid arteries, the first about half an inch, and the latter aboiit foiu'-fifths of an inch, from the free sui-face of the gland, with the internal jugular veiu, the vagus and glosso-pharyngeal nerves. The muscles of the soft palate run ia pairs, and imder normal conditions act in concert. The levator palati arises from the apex of the petrous portion of the temporal bone and the inferior cartUagiaous portion of the Eustachian tube ; the fibres jiass downwards and inwards to be ' inserted into the superior surface of the velum, interlacing at the middle liae. These muscles elevate the soft palate and contract the orifice of the Eustachian tube. The tensor palati arises from the scaphoid fossa and partly from the Eustachian tube. Its fibres pass vertically downwards to the hamiilar process, where the muscle be- comes tenduious, and is reflected at a right angle ; it is separated from the process by a small bursa. The tendinous fibres expand, and passing transversely iuwards iuterlace wdth the opposite muscle, and become inserted ruto the inferior surface of the velum. These muscles stretch the soft palate, and during swallowing open the Eustachian tube and admit air to the tympanimi. The azygos uvulte (so called from having formerly been supposed to be a single muscle) arises from the posterior nasal spine and from the posterior portion of the mucous membrane which encloses the uvula ; its office is to contract the uvula and draw it backwards. The palato-glossus forms the mass of the anterior pillar of the fauces ; it is attached superiorly to the aponeurosis of the velum, and below is inserted into the tongue. It is a constrictor of the isthmus. The palato-pharyngeus forms the posterior pillar of the fauces, and arising in the soft palate by fibres connected with those of the opposite side, passes partly above andpartly below the levator palati and azygos muscles. After f onning the pos- terior pillar of the fauces the more internal fibres go to the mesial line, and are inserted into the j^harjTigeal aponeiu'osis, the middle become lost in the aponeurosis of the veltun, and the external pass forwards and are inserted into the posterior border of the thyroid cartUage. These muscles contract the isthmus, and, acting with the levatores palati, keep the soft palate horizontal. The aj'teries are derived from branches of the external carotid, viz. : the facial, the internal maxillaiy, and ascending pharyngeal. The pterygo-palatine twig of the internal maxillary and the ascending palatine branch of the facial artery supply the veliun, though the latter is more particularly distributed to the mucous membrane, muscles, and glands, the aperl.m'e of the Eustachian tube, and its neighbourhood. The tonsillar branch of the facial artery supplies the tonsU, the sides of the pharynx, and the root of the tongue. The veins form two plexuses : the posterior, which is associated with the venous system of the nasal mucous membrane ; and the anterior, associated with the tongue, and passing into the internal jugular by THE EXAMINATION OP THE PHARYNX. 7 means of the pharyngeal vein. The lymphatics are aiTangod, as the veins in two plexuses, con-esponding with those of the nose and root of the tongue ; they pass into glands sitiiated at the bifur- cation of the common carotid, and in the region of the greater comu of the hyoid bone. , • . - v The motor nerves of the soft palate are : the motor portion ot the lower division of the fifth which suppUes the tensor palati through the Otic o-an?lion; the facial supplying the levator palati and azygos uvula3 through the connection of its trunk with the Vidian by the petrosal nerves, and the palatine brajiches of Meckel's ganglion which supply the palato-glossus and palato-pharyngeus The sen- sory nei-ves are derived from the second division of the Mth (its nasal ganglion), which supplies the anterior surface of the velum. 'The o-losso-pharyngeal, vagus, and spinal accessory fuimsh twigs to the lateral and posterior portions of the soft palate and the tonsil. 'The chorda tympani presides over the secretory functions. THE EXAMIisTATION OE THE PHAEYNX. The pharynx is not entirely accessible to direct vision, and the laryngoscope or phaxyngoscope (as the instrument h^s been cailed -when employed to examine the upper part of the throat) is requisite for the inspection of certain parts. Further, from the situation and conformation of the pharynx, some regions can only be investigated by means of probes or by digital exploration. In making an ordinary examination, it is best to use the large frontal mirror of the laryngoscope. The patient should be directed to open his mouth and take a deep inspiration. The tongue should then be gently pressed •down -with a spatula, or, better still, with the handle of a laryngeal mirror. Sometimes, however, this organ is so unruly, and the patient so sensitive, that the slightest pres- sure will produce retching. Under these circumstances a view can often be obtained, without touching the tongue, Avhen the patient inspires deeply ; or the tongue may be protruded, and firmly but gently grasped between the thumb and index finger of the operator, enveloped in a towel or napkin. If the patient at the end of deep inspiration then utters the vowel " a," the soft palate and uvula, as well as tlie pillars of the fauces, will come into view. The first object which attracts attention is the uvula, Avliich in health is about a quarter of an inch in length, and of a pale red colour, lilce the palpebral conjunctiva. Erom the margin of the uvula on either side at its base. 8 DISEASES OF THE THROAT AND NOSE. presenting a crescentic border directed downwards, is tlie free border of tlie velum, or curtain, of tlie palate. Tliis free border, when it reaches the side of the pharynx, becomes continuous with the posterior pillar of the fauces. About three-eighths of an inch above the base of the uvula on either side is the inner termination of a second cres- centic ridge, which, passing outwards, forwards, and down- wards, becomes continuous, at the side of the pharynx, with the anterior pillar of the fauces. Bounded by these pillars or ligaments, anteriorly and posteriorly on each side, are the tonsils, which in health do not project beyond the borders of the pillars. Between the two posterior piUars^is^ the posterior wall of the pharynx, which, in common with all the other parts of this cavity, is lined with mucous mem- brane. It is a frequent seat of disease, and always deserves a close inspection. In health it is of a deeper red colour than the uvula; its surface is smooth and shining, and studded here and there with the minute elevations of the mucoiis follicles. Small veins and arteries are also seen coursing along its surface — generally taking a vertical, or- obliquely vertical, direction. The inferior portion of the pharynx is situated immediately behind, and partly below, the entrance of the larynx, and it sometimes happens that foreign bodies become impacted in this situation. They still more often become lodged in the pharyngo -laryngeal sinus, a small cavity at the lower part of the pharynx, on each side, bounded externally by the side of the pharynx, and internally by the thyroid car- tilage. In some cases the cavity can be inspected with the laryngoscope, but in others it is concealed. Under these circumstances, in young siibjects, or in persons with a short neck, the finger can often determine the exact position, and frequently effect the removal of a foreign body. In other cases, probes and forceps have to be employed. For examining the upper part of the pharynx, a small laryngeal mirror should be used. In this situation, digital examination is, however, also very useful. The mouth being widely opened, the operator can pass his index finger upwards behind the soft palate, and the vault of the pharynx and its posterior wall in the upper region, as well as the orifices • of the posterior nares and Eustachian tubes, can be thoroughly explored. PHARYNGEAL INSTRUMENTS. PHARYNGEAL INSTEU^CENTS. Probes— Special probes are not requii-ed for the pharynx, those used for the larynx (hereinafter described) answering the purpose perfectly well. Brushes.— Fov applying solutions to that part of the pharynx which is visible on direct inspection, a camel's- hair pencil attached to a straight piece of aluminium wu-e, and fixed in a wooden handle, is all that is requu-ed. Tor applying remedies to the upper and lower part of the pharynx, the ordinary laryngeal brushes (see Laryngeal Instru- ments) answer every purpose. The Spatula— This instrument (Fig. 1) resembles a long tapering wooden penholder, cut flat at both ends, so as to present a larger and smaller surface for receiving the caustic paste. It should be made of oak, box, or some other hard, wood. It is very useful for applying caustic paste in cases of granular pharynx. Fig. 1. — The Phaetngeai, Spatula. Fig. 2. — The Phabyngeai, Bistotjet. The Bistoury. — This knife (Fig. 2) is like an ordinary sharp-pointed bistoury, except that the shank of the instru- ment shoidd be about five and a-haK inches long, and only the last quarter of an inch should have a cutting 'edge. This, is the most serviceable instrument for opening abscesses. Forceps and Scissors. — For removing growths from the pharynx, forceps and scissors are sometimes required. These instruments should be about eight inches in length. The forceps should have sharp teeth, and the scissors should be slightly curved. The Plburynrjeal Curette. — This instrument (Fig. 3) consists of a sharp loop of metal (somewhat resembling a curry-comb when its two ends are held in the hand), which can be fixed at any angle to its shaft, by means of a ball-joint and lock. It is extremely useful for scraping away the inspis- sated secretion in cases of follicular disease, especially when the affection occurs at the lower part of the pharynx, or 10 DISEASES OF THE THROAT AND NOSE. attacks tlic epiglottis. It may also be used for tearing .away adenoid vegetations from the vault of the pharynx. The Tonsillotome. — Instruments for removing the enlarged tonsil are now very frequently em- ployed, and the manner in Avhich they came into use will be best under- stood from a short historical retrospect. When excision of the tonsils became a recog- nized method of treatment the aid of mechanics "was soon called in to elfect an easy and rapid operation. "We are indebted to an American surgeon for the first tonsillotome. The idea of tills instrument appears to have been derived from the uvulatomes in use in this country at the end of the eighteenth century. Benjamin Bell,' in his classical vrork, described and figured an uvula guiUotiae. It consisted essentially of a flat piece of metal with an eUiptical opening at the distal extremity, and a broad semi-cir- cular blade, which when pushed forward closed the opening and cut off the uvula. In the year 1827 Dr. Physick,^ of Phila- delphia, not only improved the uvulatome, but had it made on an enlarged scale, and used it for the tonsUs. In modifying the iustrument Dr. Physick added the stout handle at its lower part, which greatly facilitated the application of the instrument, and enabled the operator to press it fia-mly to the side of the throat. Five years after Physick' s invention Fahnestock-' devised and described an insti-ument for ex- cising the tonsils, which he called a sector ton- sillarum. This instrument has been largely used in France and Germany, and indeed throughout the whole world it is known as Fahnestock's guillotine. Originally it con- _ sisted of a canula tei-minating in a cu'cular " ring, guarding a blade of similar shape, with concentric cutting edge. On being placed over the tonsil the cutting ring was with- drawn by means of a handle attached to the ■camda, and the gland was divided fi-om behind forwards. As soon as the instrument became the property of the sui-gical world it 1 " System of Sm-gery." 1783, vol. iv. |p. 144, Plate lii. Fig. 1. Bell himself preferred a probe-pointed bistoury cuived at the end almost to a semi-eu-cle (same page and plate) . Wliatever insti-ument was used the uvula was pteadUy held, and the mouth kept open by a speculum oris or mouth dilator (Plate liv.) '•i"Amer J Med Sci," vol. i. p. 2-^2. Messrs. Tiemann i: Co.. ofAew\ork, state that thev manufactured a tonsillotome about the year 1828 or 1829, and. according to a letter lately placed in my hands by Dr. Beyerley Eobm,ou of New York, claim to haye been the inyentors of that instrunient. 3 " Amer J Med Sci ," 1832, vol. xi. p. 248. Description of an instrument. .&C. &c., by Wm. B. Fahnestock, M.D., of Lancn-ster, Pliiladelphia. 1 M a =s O QJ bo II w J PHABYNGBAL INSTRUMENTS. 11 imderwent numerous modifications. Guersant ' altered the shape of the rin"- from cii'culai- to elliptical — a foi-m wliich is miich better adapted to the contom- of the tonsU. The same surgeon, on the suggestion of Velpeau, added a small two-pronged fork to the ton- sUlotome by a mechanism which transfixed and drew the tonsil Fig. 4. — Physick's Tonsillotoiee. (Modified by the Author.) from its bed before subjecting it to the action of the cutting blade. Chassaignac ^ augmented the number of prongs to three, in order that the gland might be seized with greater firmness, and Maison- neuve-* made further improvements in the instrument. ' " Hypertrophie des Amygdales." Paris, 1864. '- " Le9ons sirr I'Hypertro'phie dea Amygdales." Paris, 1854. " Bull, de la Soo. de Chir." 12 DISEASES OF THE THROAT AND NOSE. Tlioi^gli Fahnestock's guillotine is almost universally used, I greatly prefer instruments made on tlie simple model of Physick, as all complicated mechanism is thereby avoided, the instrument never breaks, and can always be kept clean and sharp. With Physick's instrument also the operator has much more power in placing the tonsiUotome in situ. The guillotine which I employ is the same as that of Physick slightly modified — so that the handle can be applied to either side of the shank. This arrangement enables the operator to use the instrument Avith his right hand for amputating either tonsil, the free surface of the blade in each case being dhected Pig. 5. — Fasnestook's Tonsillotomb (as improved by French surgeons) . towards the centre of the mouth. In operating the patient should sit facing the light, and the operator with his back to it. A laryngoscopist, however, wiU always prefer to illuminate the throat with the frontal mu-ror. The in- PiQ. 6.— The Authoe's Double Tonsii-lotome. When the insti-ument is iuti-oduoea into the mouth the blades meet in the ceXe^but on KrarpiDg the two handles together, the h ades ai-e tlu-own out aeainat the sides^ of thi thi-oat, and the ton.ils received in the oval_ openings orthe tonsaiotomes. Amputation is then effected by pressmg on the rmg at the proximal extremity of the instrument m the ordmary way. stnunent being ready for use, the hilt is grasped in the right hand, and the aperture in the shank is placed over the tonsU. The surgeon, with the thumb or index iino-er of the left hand placed under the angle of the PHARYNGEAL INSTRUMENTS. 13 patient's jaw, then presses the tonsil inwards, wliilst at the same moment, with the thumb of his right hand, he drives home the blade of the tonsillotome. Professor Lucae,i of Berlin, has still further modified this instrument by adding a cup-shaped cavity over the extremity — in order to prevent the excised ton- sil falling down the throat — and by dispensing with the Avooden handle. As, however, in using Physick's guillotine the tonsU is al- ways either caught in the instrument or brought for- ward into the mouth, I do not see the use of Professor Lucae's suggestion for re- ceiving the tonsil. I may add that the wooden handle, dispensed with by Lucae, is one of the most impor- tant features in Physick's instrument, as it ensures steadiness and gives power. Some years ago Messrs. Mayer & Metzler made a double guillotine for me (Fig. 6), by means of wliich both tonsils can be simultane- ously excised. The only objection to its use is that it acts equally on both tonsUs, whUst it some- times happens that more of one tonsil requires to be removed than of the other. Tlie Uvulatome. — In speaking of tonsillotomes, it has al- ready been shown that this instrument preceded, and, indeed, gave rise to the invention of the tonsillotome. The uvula- 1 " Deutsche Medic. 'Wocliensclirift," Nos. 11 and 15, 1877. I am indebted to Mr. Detert, the well-lmown Berlin instrument maker, for a very perfect specimen of Professor Lucae's guUlotino. 14 DISEASES OF THE THROAT AND NOSE. tomes, however, wliiuli Avere in use in tliis country at the end of the eighteenth century were of very rough con- struction, and it was only when the introduction of the laryngoscope gave a great impetus to the study of throat affections, that the modern uvulatome was invented. The credit of greatly improving this instrument is due to Dr. Elsherg, of New York. His instrument consisted of a cutting hlade which Avas drawn back until placed in situ, and was then suddenly discharged by touching a trigger in its upper surface. Beneath the blade were forceps, which seized the uvula as it was cut through. Eindmg, however, that this instrument Avas inconvenient in practice, as the strong spxing imparted a great jerk to the instrument, whilst the blade often failed to cut through the uvula, I abandoned the spring and trigger arrangement and added a second cutting blade. One of the blades is pushed forward by the thumb whilst the other is a fixture at the distal extremity of the instrument. The two blades are arranged at such an angle that they correspond to the blades of a pair of scissors. In other words, as the moveable blade passes doAvn over the one that is fixed, the aperture receiving the uvula forms an isosceles triangle until it is obliterated by the complete closiu'e of the blades. In using this instrument, the free surface of the blade should always be directed upwards, and it is well to hold it somewhat obliquely, as by this means a tapering, instead of a truncated, iiAada results from the operation. CATARRH OP THE PHARYNX. 15. DISEASES OF THE PHARYNX. CATAERH OF THE PHAEYNX. (Synonyms : Pharyngitis. Sore Throat.) Latin Eq. — Catarrhus pliaryngis. Pharyngitis. French Eq. — Angine infiammatoii'e, superficielle, ou catarrhale. Phaiyngite. GermanEq. — SchlundkataiTh. ScMimdeiitzUnclung, Halsweh.^^^ Italian Eq. — Catarro della faringe. Paringitide. Definition. — Acute inflammation of the mucous membrane of the 'j^harynx, usually terminating in resolvMon, hut in cachectic persons often causing a liability to future cdtachsy and leading idtimately to relaxation of the mucous mem- brane of the pharynx. Etiology. — -Catarrh, of the pharynx affects all classes, and is common at all ages. It is most frequent, however, in young persons. The strumous diathesis, general feebleness of constitution, and long-continued exposure to any influences which tend to depress the vital powers, such as contaminated air, had food, impure water, &c., act as predisposing causes of the disease. Persons engaged in sedentary occupations, and dwellers in cities are more subject to the affection than those living an active country life. Catarrh of the pharynx is most prevalent at those seasons of the year Avhen sudden changes of temperature and inclement weather are frequent, and the exciting cause of the malady is generally exposure to cold or damp. Those who have had syphilis, or been mercurialised, are very subject to the affection. Pinally, the disease occasionally appears to arise from some pecuHar condition of the atmosphere, which seems to engender it epidemically. Symjjtoms.—The onset of pharyngeal catarrh is in most cases accompanied by slight feverish sjTuptoms, and a general feeling of lassitude and depression. These phenomena, however, may be almost entirely absent, the first symptom complained of being a disagreeable sensation of dryness, and a stiffness in the throat in swallowing. As the morbid action becomes fully developed, considerable pain may be ex- perienced in deglutition, whilst the voice becomes hoarse ' The Germans do not, as a rule, use popular names for the various inflammatoiy aifections of the pharynx, but employ the generic term anffinn for aU of them, with a qualifjnng description of the affection, thus : angina cataiThalis, a. tonsillaris, a. gangrienosa. ' 16 DISEASES OF THE THROAT AND NOSE, iinJ partakes of a nasal timbre. At the same time the patient may suffer from noises in the ears, and the sense of hearing may be temporarily impaired. The character of the symptoms depends on the extent and situation of the_ in- flammation, and some writers have divided the disease into two varieties, namely, superior, and inferior, pharyngitis.^ AVhen the upper part of the pharynx is attacked, the swallowiag and hearing are affected. On the other hand, should the disease be situated in the lower part of the throat, parti is caused by any movement of the larynx, and there is tenderness on pressure at the sides of the neck. When the whole tract of the mucous membrane of the pharynxes in- flamed, there is a combination of all the phenomena. In all cases, after the first day or two, there is a considerable mcrease of the mucous secretion, and the patient resorts to constant efforts of coughing and hacking, in order to clear his throat. As a ride, resolution soon occurs spontaneously, and at the end of a week the parts have regamed their normal con- dition. In very rare cases, however, the disease, wliich at first seemed a mild catarrh, develops into an active inflam- mation, or true pliarynqitis. The symptoms are then greatly intensified. OccasionaUy, the inflammation extends to the larynx, and the symptoms of the pharyngeal affection are lost in' the more serious phenomena of ojdema of the glottis. Cases, indeed, have been placed on record by Bamberger,- Eilliet and Barthez,^ and Eiihle,'!' ^hich have been thought to show that acute pharyngitis may rapidly prove fetal in Bamberger's cases, however, as well as in those of EiUiet and Barthez, there was probably suppressed scarlatina, whilst Eiihle's patient was also the subject of acute alcohohsmus. In feeble persons, after the acute symptoms have passed off, there sometimes remains a persistent delicacy of the mucous membrane of the pharynx, which renders the individual peculiarly susceptible to subsequent attacks of a similar Sre. Cases have been reported by Gubler,» Broadben and others, in which a simple acute inflammation of the pharynx caused subsequent paralysis of the veil of the palate. On inspecting the pharynx, in a case of ordinary catarrh, the mucous membrane is seen to be of a vmd red colour, 1 Peter- "Diet, des Sc. Med." Paii^, 1864, vol. iy. p. 695 3 » Sndbi^h der Pathologie " &e Erlangen IJ^o, Abth. 1. s. 6. 3 «' Mnlfidie des Enfants." Pans, 1855, p. 233, et seq. . VoSat's " Sannnlnng ,Klin, Vortr." Leipzig, No. 6, s. 9. 6 " ArcHves Gen. de Med. " 18o9-60. 6 "Lancet." 1871, vol. i. p- 308. CATARRH OF THE PHARYNX. 17 and to present a dry sliining appearance. Some tumefaction of the pillars of the fauces and soft palate is almost always present. Small veins, not visible at other times, may he perceived, and the uvula is often slightly oedematous and elongated. When the pharynx is more acutely affected, the mucous membrane of the posterior wall of the pharynx is swollen and of a bright red colour, looking like rich crimson velvet. Sometimes the epiglottis is also seen to be much swoUen and congested. When the inflammation is on its decline, the surface of the mucous membrane is often streaked with dark coloured viscid mucus, which adheres to the parts with great tenacity. Diagnosis. — Catarrh of the pharynx may be confounded with quinsy, but as the gland soon begins to swell when it is inflamed, the diflerentiation of the disease is quickly established. Futlwlogy. — The affection, when slight, is merely a fluxionary hypertemia ; when severe, an acute inflammation . In all cases the vessels are dilated, and the severity of the affection depends on the amount of submucous infiltration. The secretions contain a number of j)us cells and micrococci. Prognosis. — The great majority of cases terminate in reso- lution, and leave no troublesome after-effects. In cachectic persons, however, as already remarked, a permanent Aveakness of the mucous membrane is often the consequence of catarrhal inflammation, and the individual is rendered liable to repeated attacks of the same kind. Treatment. — Few persons think it necessary to take medical advice, on account of an ordinary pharyngeal catarrh. Confinement to the house for a day or two, restriction to a light diet, and the avoidance of stimulants, are the only measm'es required in order to allow the disease to undergo spontaneous resolution. A wet compress, or mustard poultice to the neck, a hot foot-bath, and sucking ice expedite the cure. An opiate, especially the tincture of opium, taken early in the day — if possible, will generally cut short an attack. The stimulating effect of oj^iates is greatly di- minished if the patient sleeps immediately after taking a dose. Hence the old plan of administering Dover's powder just before going to bed does not answer so well as that now recommended. From five to ten drops of laudanum generally produce the best efi'ect. Larger doses act as a sedative, and instead of controlling the vascular action, lead to relaxa- tion. A Turkish bath is a popular remedy which will also c 18 DISEASES OP THE THROAT AND NOSE. frequently cut short an attack of pliarjaigeal catarrh. The disappearance of the local affection may, generally, be considerably hastened by prescribing a rhatany lozenge every three or four hours. After the acute symptoms have subsided, the mucous membrane may be braced up by astringent solutions. A few applications of the pigment of chloride of zinc or perchloride of iron (Throat Hosp. Phar.) are especially useful for this purpose. The disposition to pharyngeal catarrh is best counteracted by the use of a cold bath in the morning, when sufficient reaction follows. The skin should, if possible, be made less sensitive by the use of rough towels and flesh brushes, whilst hot rooms, late hours, and all habits calculated to relax the system, should be strictly avoided. UvuLfTis. In some cases where the pharynx is inflamed, the violence of the morbid action appears to be expended on the .uvula. Under such circumstances this part becomes intensely red, swollen, and elongated, or it may be highly cydematous, and have a pale translucent appearance. It may attain the thickness of one of the fingers, and hang down into the sulcus, between the epiglottis and tongue,_ or even pass into the larynx and give rise to distressing paroxysms of dyspnoea. The treatment should consist of scarification or ampu- tation. When the oedema is slight, the uvula may be scarified by means of a sharp-pointed bistoury. In a few houi-s after the operation the part generally returns to its normal size. When, however, the inflammation is very active, scarification sometimes only gives exit to a few drops of blood, and in such cases the best procedure is to amputate the end of the uvula Avith the uvulatome. A discharge of watery blood at once ensues, which greatly relieves the engorge- ment both of the uviUa and the surrounding parts. Under these circumstances the inflammatory action usually under- goes rapid resolution RETRO-PHABTNGEAL ABSCESS. 19 EETEO-PHAEYNGEAL ABSCESS. (Stn. : Post-Phartngeal Abscess.) Latin Eq. — Abscessus post-pharyngeus. French Eq. — Abces retro-pharyngien. German Eq. — Ketro-pharyngeal Abscess. Italian Eq. — Ascesso retro-fariugeo. Definition. — An inflammatory sioelling containing 2nis in the posterior wall of the pharynx. Etiology. — This is essentially a disease of childhood, though it occasionally attacks adid.ts. The youngest children may siiflfer from it, and several cases are reported in which the disease occiUTed in sucking infants.^ The male sex does- not show the preponderating predisposition to the affection which is seen in many other diseases of the throat. Bokai- has collected 144 cases, and of these 78 were boys, and 66 girls. It used to be supposed that the disease Avas most commonly the result of scarlatina, but Bokai's cases have clearly proved that the affection is generally idiopathic. The following table abridged from that author well illustrates the causes of retro-pharyngeal abscess : — 129 cases were idiopathic, 7 appeared in the course of scarlet fever, 4 were due to cervical spondylitis, 3 were of hypostatic character, 1 was traumatic — due to a foreign body. In a large niunber of the idiopathic cases tlie little patients exhibited a scrofidous diathesis. In adults ab.scesses, not larger than a pea, sometimes form in the wall of the pharynx as the result of catarrh, but these cases do not belong to the class now under consideration. Symptoms. — The inflammatory process which leads to the formation of an abscess behind the posterior wall of the pharynx is generally of an insidious nature. In most cases the symptoms are not sufficiently prominent to attract atten- tion until the local sweUing interferes seriously with respii-a- 1 See a case by Besserer : "Abscess an der hintem Waud des PharjTix bei einem vier Monat alten Kinde," Schmidt'? Jalirb., 184o, p. 198; also a case by Winteinitz : " Eetro-pharyngeal Abscess iiii SaugUngs' Alter" : "Wochenschrift der Gesellschaft der Aerzte iu Wien, 1861, p. 2-11. * Jahrbuch fiir Kinderheilkunde, 1876, Heft 1 imd 2. 20 DISEASES OP THE THROAT AND NOSE. tion and deglutition. On inspection of the pharynx, if the abscess is situated high up, the mucous membrane of the posterior wall can be seen bulging forwards, and presenting a red, smooth, and uniform surface — indicative of tension. On passing the finger (which in the case of children, in order to avoid being bitten, should be protected by being partly "wrapped in a cloth) into the 'back of the mouth, a soft tumour can be perceived. When the abscess is in the lower part of the pharynx, its presence can be determined with the aid of the laryngoscope. The symptoms vary somewhat according to the position of the abscess. If the tumour is situated at the upper part of the pharynx, deglutition, especially of solids, is difficult, and the voice partakes of a nasal intonation, but the occlusion of .the passage is not usually sufficient to incommode respiration. When the bulging of the pharyngeal Avail occui-s opposite the larynx suffocative attacks are likely to be frequent and may prove fatal, whilst swallowing may, at the same time, be interfered with to a serious extent. If the abscess occupies the sides of the pharynx there is great danger that the pus may burrow into the cellular tissue of the ary-epiglottic folds and thus produce oedema of the glottis and fatal dyspnoea. In addition to the phenomena consequent on obstruction of the degluto-respiratory canal, there may be stiffness of the neck, or the head may be drawn to one side or thrown backwards, owing to extensive infiltration of the areolar tissue betAveen the pharynx and vertebral colimm. Bokai considers that the position of the head affords a valuable diagnostic sign. When the abscess is situated laterally, as occurs in three-fourths of the cases, the head is incUned towards the healthy side. In some cases tumefaction of the lateral and posterior parts of the neck may be present, whilst contraction pf the sterno-mastoid muscle may be so marked as to give the idea of tetanic spasm. During the first years of life, convulsions almost constantly accompany the dis- ease, and Bokai observed facial paralysis in three cases. There is seldom, however, any fever in children. The symp- toms of post-pharyngeal abscess often exhibit a remarkable resemblance to the phenomena of croup, for Avhich disease I have known pharyngeal abscess to be mistaken on several occasions. In the majority of cases, a sudden termination of all the symptoms is brought about by the spontaneous bui-st- ing of the abscess, but in some instances the quantity of pus is so great as to suffocate the patient in its sudden RETBO-PHARYNGEAL ABSCESS. 21 evacuation.! "Wendt^ states that the abscess, when left to itself, may give rise to listuloiis tracks which extend in the direction of tlie thoracic cavity or in the skin of the neck. According to Bokai, Avhilst idiopathic abscesses form rapidly — often in two days — secondary abscesses require a week or more for their development. Abscesses proceeding from disease of bones are still more chronic in their course. In conclusion, it may be observed that should the abscess depend upon caries of the vertebral column, the fact can generally be asoertnined by noting whether pain is caused by pressure on the spinous processes of the cervical vertebra^.. Diagnosis. — Eetro-pharyngeal abscess may be confounded with croup, with a foreign body in the larynx, or with oedema of the glottis. With respect to croup, the diagnosis can easily be established by attention to the condition of the vocal and deglutory functions in the two diseases. Thus, in croup, the voice is soon extinguished, Avhereas in post- •)haryngeal abscess, it is usually only altered in intonation, Again, in croup there is no dysphagia, Avhereas in retro- pharyngeal abscess difficulty of swallowing is as prominent a symptom as dyspna?a. . In addition, portions of false mem- brane being frequently coughed up in the croupous affection, the diagnosis may often be established from the appearance of the expectoration. The physical examination of the throat, when possible, will of course determine the nature of the disease. As regards a foreign body in the larynx, its presence may evoke symptoms similar to those of retro-pharyngeal abscess, but phonation is generally more troubled than in the latter affec- tion. The history of the case, and the use of the laryngoscope, will, in many instances, complete the evidence as to the impaction of a foreign body in the larynx. On reference to the symptomatology of retro-pharyngeal abscess, it will bo seen that a veritable oedema of the glottis sometimes occurs through extension of inflammation, or j^urulent infiltration, to the ary-epiglottic folds. The phenomena of the two maladies are thus occasionally combined. Patholorjy. — The origin of these abscesses is probably to be found in the structure of the part attacked. The abundance of glandulce in this situation has long been recognized, and the peculiar arrangement of the lymi^hatic vessfels, as de- scribed by Dr. Edmund Simon,^ is still more remarkable. ' See a case by Gaupp : " "Wurtemb. Con-. Bl." xl. No. 23, 1870. 2 Ziemssen's " C'vclopreclia," vol. vii. p. 68. » "Scbniidt's Jahrbuch," vol. cvii. p. 161. DISEASES OF THE THROAT AND NOSE. These conditions provide the nidus for the development of scrofulous inflammation, which is so likely to occur in young children jiredisposed to the disease by diathesis. The oc- currence of abscess in cases of spondylitis is only in accord- ance with the phenomena commonly observed in inflammation of the osseous structures and their protecting periosteum. Prognosis. — A favourable teiaaination may generally be anticijjated when the abscess is diagnosed early and a fi-ee exit given to the pus. SjDontaneous evacuation of the matter is also commonly followed by an immediate amelioration of all the symptoms. The prognosis is most unfavourable where the abscess has been allowed to interfere with deglutition and respiration for so long a time as to produce slow aspliyxia and marasmus. In those cases where the disease is connected with caries of the vertebra, the presence of a constitutional dyscrasia, and the impossibility of removing the cause of the affection, render the prospect of recovery less hojDeful. Mr. Syme,'- however, has reported a case in which recovery took place after the exfoliation of the greater part of the second cervical vertebra ; and Giinther^ relates a still more remarkable instance in which the patient recovered after the removal of the third and fourth cervical vertebrae. Both these cases were probably syphilitic. In cases of spondylitis the malady pursues a tedious course, which exhausts the vital powers, and the abscess, if opened, is not unlikely to fiU again.^ As already pointed out, the sudden rupture of a large retro- pharyngeal abscess may give rise to immediate suffocation, and it must not be forgotten, as already pointed out, that, in infants, the formation of the pus is sometimes accompanied with convulsions. The prognosis may be gathered from a consideration of Bokai's cases."* The idiopathic cases are the least fatal, for out of 129 cases only 5 proved fatal. Of the 7 patients with scarlet fever 2 died, and of the 4 cases of cervical spondylitis 3 terminated fatally. The traumatic case also resiTlted in death. Treatment — If pus has not actually formed the case should be treated by ice both externally and internally. If sup- puration has occurred prompt evacuation is the proper treat- ment. It has been suggested" that these abscesses may be 1 "Edin. Med. Jom-u." AprU, 1826, p. 311. 2 " Deutsche Klinik." 1856, p. 34. (Both this reference as -well as the last one are given by Dr. Solis Cohen: "Diseases of the Throat, Philadelpliia, 1872, p. 150.) , , , j 3 In a case recorded by Abercrombie, the abscess had to be opened three times before tlie process of siippiu-ation terminated. Quoted by Peter: "Diet, des Sciences Med." Paris, 186-1, vol. iv. p. 698. i Loc. cit. Niemeyer, 7th Genn. Edit. p. 519. RELAXED THROAT AND UVULA. 23 opened with the nail of the forefinger, but it is better to effect free evacuation by an incision at the most dependent part with the laryngeal lancet. Some practitioners recommend that a trocar sho°ild be employed with the view of avoiding the danger of the pus flowing into the larynx.^ In all cases tliis contin- gency should be guarded against by bending the head promptly forwards the moment the incision has been made. Whilst the local aflection is being attended to, constitutional treat- ment Avin usually be necessary in order to re-invigorate the depressed vital powers. In strumous cliildren, cod- liver oil, phosphate of iron, and iodide of potassium wiU generally prove useful remedies, whilst in infants the tendency to convulsions may often be successfully combated by bromide of potassium administered every three or four hom-s in five-grain doses. Finally, when convalescence is established, a change of air and a conrse of sea-bathing will, in most instances, resuli m fhe re-establisment of the patient's health. EELAXED THEOAT AND UVULA. (Synonym : Chronic Catarrh of the Throat.) Lutiti Eq. — Eesolutio faucium. Uva descendens. Jrencli Ecj. — Eelachement. Atonie du pharynx. Elonga- tion de la luette. Chute de la luette. German Eq. — Erschlaftung der fauces. Verlaugerung des Zapfens. Italian Eq. — Eilassatezza delle fauci. Ugola allnngata. Definition — Relaxation ivith slight congestion and swelling ■of the mucous membrane of the fauces and an increase in .the lengthj and occasionally in the breadth, of the uvula. Etiology. — Eelaxation of the throat and uvula, in by far the greater number of cases, probably originates in catarrh, ■or rather in repeated attacks of catarrh. The acute symp- toms pass off, but the tissues do not recover their normal tone, and the result is a certain looseness of texture. Eelaxed throat is a very common aflection in variable climates, espe- •cially in those countries where there is a frequent combina- tion of cold and wet weather. In some persons exposure to night air always brings on the aflection. Prolonged stay in ' Abeliu : " Retro -pharyngeal Abscess in Toimg Children." Nordiskt Mediciuskt Arkiv. Stockhobii, 1871, iii. No. 21. J 24 DISEASES OF THE THROAT AND NOSE. oveilieatetl rooms, on the other hand, especially where much gas is burnt, may also give 1-ise to it. Those wlio, Avhilst leading a sedentary life, are inclined to the pleasures of the table and a free indulgence in spirituous liquors, often suffer from relaxed throat. Indeed, the worst cases generally arise from the hal3itual abuse of the stronger forms of alcohol. In such, cases there is often a sub-acute catarrh of the stomach, "which extends upwards through the oesophagus to the pharynx. The affection when occurring early in the morn- ing is brought on, from exposure or exce.ss the previous even- ing, from hypostatic congestion of the throat occui-ring in the recumbent position, or perhaps from sleeping with the mouth open and the consequent drying of the mucus on the surface. Wlien the relaxed condition, however, only causes trouble in the evening, it tben probably results from fatigue. In a few instances relaxed throat appears to be due to some reflex irritation, and women suffering from uterine complaints are often troubled with this affection. Eelaxation of the uvula may also arise in scrofulous children in whom there is often a generally relaxed condition of the system. In a few cases an abnonnal length of the uvula has been ob- served to be a congenital malformation. Paralysis of the veil of the palate, consequent on progressive bidbar disease or diphtheria, also produces a falling of this part. Eelaxation of the pharynx rarely leads to any serious alterations in structiu-e, and, though it may persist for years, seldom gives rise to anything more than a temporary incon- venience. Symptoms. — On wakuig after a night's rest a person affected with relaxed pharynx experiences a peculiar fulness and stiffness of the throat, often accompanied with a dis- agreeable sensation, as if due to the presence of a foreign body. The throat feels dry and parched, and repeated efforts are made to dislodge the supposed cause of irritation. These symptoms may last for days together, but they often subside as soon as the patient has taken a sip or two of hot coffee or tea. The examination of the throat sometimes aftbrds only negative results, but in most cases the fauces are seen to be relaxed and slightly swollen, the whole of the palate depen- dent, and the uvula elongated. There is also generally a varicose condition of the smaller veins. Sometimes the surface of the pharynx has a peculiar pellucid appearance from being covered by a transparent film of mucus. When the uvula is much affected the symptoms arc more troublesome RELAXED THROAT AND UVULA. 25 and very persistent— a distressing, tickling cougli often con- tinuint^" during the Avhole day. In the worst instances the uvula '^may he so much lengthened as to he drawn into the larynx in inspiration. This event usually occurs -when the patient is sleeping on his hack, and he awakes suddenly with a suffocative attack. In cases of this kind the ahnornial condition of the organ often produces nausea and vomiting hy irritating the fauces and hase of the tongue. On inspection the relaxed state of the uvula can°at once he perceived. The mucous memhrane and sub-mucous tissue are the structures affected, there being usually no increase in the bullc of the azygos uvulas muscle. The mucous membrane sometimes forms a kind of opaline vesicle at the extremity of the uvula, and from this point a constant dripping of watery mucus may take place. It must not be forgotten, however, that considerable elongation of the u\T.ila may sometimes exist without giving rise to any marked subjective symptoms. Pathology. — The blood-vessels are dilated and gorged, and the tissues generally either swollen from serous infiltration, or thickened by semi-organized products. The glandulte are usually both dilated and hypertrophied. Frogiiosis. — A cure can nearly always be effected, if the patient avoids the causes of the disease, and submits to proper treatment. Treatment. — The various exciting causes already referred to must be carefully avoided, and the patient must live in a dry and bracing atmosphere. If there be any hepatic conges- tion, or irregularity of the bowels, a glass or two of Friedrichs- hall or Pullna Bitter Wasser, should be taken early in the morning. If the affection be slight, the free use of a gargle of chlorate of potash, night and morning, will sometimes quickly reUeve the unpleasant symptoms. Mildly astringent lozenges, such as rhatany and kino (Throat Hospital Phar.), taken four or five times a day, are very useful. When the affection is obstinate the local application of astringents, such as solutions of perchloride of iron (3j. ad gj.) or chloride of zinc (grs. xxx. ad gj.), combined with the internal use of tonic remedies, will sometimes effect a cure. If, however, the uvula is much elongated and occasions troublesome symptoms, it should be shortened. Abscission of this fold of mucous membrane has been practised from a very early date.i The ordinary method is to cut off' a smaU portion with a pair of ' See Aretfetis Uepi oiTiaJc Kal ariixelciiv, k.t.K., LI. cap. viii. 26 DISEASES OF THE THEOAT AND NOSE. scissors, whilst the extremity of the uvula is held with forceps. The operation is, however, more eflficiently and rapidly performed with the aid of the uvulatome, in the manner already described. Occasionally severe and continuous hremorrhage follows the I'ttle operation, but it can always be checked by slowly sipping a teaspoonful or two of the tanno- gallic gargle of the Throat Hospital Pharmacopoeia. The immediate effect of the operation is generally to cause a painful sore throat. The patient can only swallow liquids, and even these cause pain. There is indeed sometimes odijnphagici of the most severe character. Occasionally the pain extends to the ears, and severe spasmodic contractions of the pharynx may take place. In some instances, on the other Irand, the operation does not give rise to any trouble, and in most cases the pain passes off in a day or two. The soreness of the throat may be greatly relieved by frequently sucking a marsh- mallow lozenge (Throat Hosp. Phar.). The bland substance of the lozenge adheres to the wound, and forms a protecting covering. The -wound soon ieals, .and the advantages which residt from the removal of the part are in most cases almof5t immediately experienced. The irritating fits of coughing at once subsifle, and a very great improvement often takes place in the patient's general health. In cases loliere there is any follicular disease of the throat, it is most important to cure 'that affection before the uvida is anumtated, as owing to the after-pain caused by the removal of the uvula, patients will not submit to any further treatment, when they have recovered from the operation. Hence the patient remains uuciu-ed, and the operation, and he who performed it, are brought into discredit. ULCEEATED THEOAT. Latin Eq. — Fauces ulcerosae. French ^g — Ulcerations de la gorge. German JJj.— Geschwilrige Pharynxentzlindung. Italian Eq. — Angina ulcerosa. Definition. — A superficial ulceration of the fauces, due to slight septiccemia. ^//oZor/?/.— Ulcerated throat is an affection often encoun- tered in 'debilitated persons exposed to the influence of septic poisons. During epidemics of anguiose scarlatina, or of diph- theria this form of sore throat is frequently observed amongst the attendants of the sick. The disease generally manilests ULCERATED THROAT. 27 itself in persons who have been long exposed to unhealthy influences, or in those who have become weakened from con- stant watching, loss of rest, and insufficient exercise. Students who are diligent in hospital practice, and those passing much time in the dissecting room, are peculiarly liable to ulcerated sore throat, called by the Germans angina nosotomii. Symptoms. — The first symptom of ulcerated sore throat is odynphagia, which is especially noticed in swallowing the saliva. The throat feels stiff and swollen, the tongue is furred, and the breath offensive. The pulse is generaUy weak, and the temperature slightly raised. There is great loss of appetite. Though the patient feels drowsy he is often unable to sleep, and there is a sense of general malaise and lassitude, and sometimes shooting pains in the limbs are experienced. The patient also frequently suffers from a splitting headache. On examination it will be seen that the tonsils are somewhat swollen and congested, and that there are one or more small, white, superficial ulcers on the sur- face of the tonsils or fauces. The ulcers are generally round or oval, and vary in size from that of a millet seed to a shilling, but they are sometimes even larger ; when there are several ulcers they show no disposition to become confluent. Diagnosis. — The conditions imder which the disease arises, and its rapid development facilitate its diagnosis. The idcers are seldom covered by any deposit or membrane, and there is generally no difliculty in determining the nature of the affection. Pathologij. — The disease is probably a low form of inflam- mation, in which there is a slight alteration in the constitution of the blood. The nutrition of the part is impaired, and molecidar death takes place. Prognosis. — This is always most favourable. Treatment. — The patient should at once be removed from the insalubrious surroundings, and have the advantage of healthy atmospheric conditions. The bowels should be evacuated by the administration of a mild aperient, but, on account of the generally asthenic nature of the afl'ection, mercurial cathartics are to be avoided. To combat the fever and the symptoms of septicajmia, quinine and ammonia should be administered as soon as the tongue has cleaned ; and to relieve the local condition, antiseptic gargles (Throat Hospital Phar.) are often useful, especially those containing chlorate of potash, per- 28 DISEASES OP THE THROAT AND NOSE. manganate of potash, borax, carbolic acid, or chlorinated soda. Mildly astringent lozenges, such as rhatany or kino (Throat Hospital Phar.) may frequently be used with advantage. In some cases, however, owing to the great swelling, gargling and sucking lozenges are a^ttended with so much pain that we must resort to some other plan of local medication. Under these circumstances the use of inhalations sometimes gives reUef, and a sootliing vapour, such as the Yapor Benzoini or Vapor Conii (Throat Hospital Phar.) may render good service. Warm inhalations are especially indicated when the inflammation is slight and circumscribed. On the other hand, when the inflammatory process is very acute, sucking ice answers best. Ice, applied in a bladder to the head, also at once removes the cephalalgia, so often present. The patient should be fed on bland and nutritious fluids, and a few glasses of good wine, well diluted with water- will be of service. Under suitable treatment the patient rapidly improves, and convalescence is generally thoroughly established in a few days. GRANULAE PHAEYNGITIS. (Synon. : Follicular Pharyngitis. Granular Pharynx. Clergyman's Sore Throat. Chronic Pharyngitis.) Latin ^g-.— Djsphonia clericorum. French Eq.—Angine glanduleuse. Angme granuleuse. Angine papillaire. Pharyngite glanduleuse. Pharyngite granuleuse. German Chronischer Pharynxkatarrh. Chronischer Pharyngitis. Italian ^2.— Faringitide cronica. Definition.— C/iro?i{c inflammation of the follioies of the Vhnrynx occurvmq in two forms— the hypertrophic and the exudative. In the hypertrophic the diseased glands or the epithelial structures become enlarged, and appear as elevated qramdar bodies on the surface of the mucous meinbrarte. In the exudative the glands give exit to a white, inspissated secretion, which projects from the point of tssue or adheres m patches to the mucous lining of thephari/nx. ^ hat relatiom- if any— the two forms hear to each other has not been determined. GRANULAR PHARYNGITIS. 29 History. — The existence of this disease was scarcely recog- nized nntil 1846, when ChomeP published some reitlarks on a special state of the pharynx, Avhich he called I'aiigim ,/mmileuse. Nevertheless, as early as 1741, Van Swieten^ had mentioned in his commentary on Boerhaave that the " mucous crypts " of the pharynx, larynx, and oesophagus, Avhen obstructed and swollen, gave rise to troublesome symptoms, and to deficiency in the mucous secretion. The monograph of Chomel had scarcely been perused by the body of the profession when Horace Green,^ of New York, published a treatise on the same subject based on careful observations of the malady during a period of more than six years. He gave a good description of the disease under the name of follicular disease of the pharijmjo-laryngeal mem- hrane. In 1851 Buron'* read a thesis on chronic pharyngitis confirming the observations of Chomel, and in 1857 Gueneau de Mussy= stiU further elucidated the subject in the most systematic and exhaustive monograph that has yet appeared. The literature of the disease is now extensive, but although the objective and subjective symptoms have been well described, there is still considerable divergence in the views of the various authors, especially with respect to the pathology of the affection. The morbid anatomy of follicular disease of the degluto-respiratory tract has not yet been studied sufficiently thoroughly to enable us to determine the exact relations which the various appearances presented during life bear to each other. Etiology. — The causes of follicular pharyngitis are pre- disposing and exciting. The strmnous, gouty, and rheumatic diathesis^ predispose to the disease. Heredity is con- 1 "Gazette Medicale." 1846, p. 310. - " Comment, in H. Boerhavii Aplior. de Cognosc. et Our. Morbis, Lugduni Bat." 1741, vol. ii. p. 575. ^ " A Treatise on Diseases of tlie Air-Passages," &c. New York, 1846. * " De la Pharyngite Clu-onique, Thfese de Paris." 1851, No. 203. " " Traite de I'Angine Grlanduleuse." Paris, 1857. " Since Gueneau de Mussy published his work, already referred to, French physicians have regarded the hei-petic diathesis as a very frequent cause of the affection. The temi "herpetic" is, however, HO vague that I do not feel myself justified in makiag use of it. The most complete definition of the diathesis and its manifestations is given by Bouchut et Depres in their " Dictionary of Medicine." In the following extracts the terms, diathese clarti'ousc, diathvsc hcrpetiquc, and herjjetisme, are synonymous : — Dartres — " Les maladies de la peau qui dependent d'une diathese autre que la syphilis, la scrofule, le rhumatismc ou 1' alteration du 30 DISEASES OF THE THROAT AND NOSE. sidered by Green^ to be an influential factor in its pro- duction. A majority of cases are met with between the ages of twenty-five and thirty-five years,^ but the affection frequently shows itself much earlier. Thus Gueneau de Mussy^ nientions instances occurring in children under fifteen years, and I have met with the disease in children of eight, six, and even three years of age. Amongst adults the malady is more common in the male than in the female sex — a fact which can perhaps be explained by the much greater exposure of men to the exciting causes. The delicate state of the mucous membrane of the throat, which often remains after severe attacks of influenza, scarlatina, measles, and small-pox, some- times appears to render the individual liable to follicular disease. The most potent of all the exciting causes of granular pharyngitis is over-exertion of the voice. In those of sound constitution and good muscular development considerable exercise of the vocal organ is not followed by any bad eftects, but, on the contrary, such exertion rather acts as a local' tonic. When, however, the vital powers are naturally feeble, and the bodily conformation ill-adapted for prolonged and forcible effort, the over-exertion of any organ invariably impairs the activity of its functions and produces disease. A very large proportion of the cases of granular pharyn- gitis which have come under my notice have been amongst sano- par les poisons et les virus sont des dartres. La disposition de ror^anisme qui favorisel' apparition des dartres constitue Z herpctisme. "°Pendant la jeunesse les dartres (furfuracees, papuleuses, vesi- culeuses, pustvi^euses, squameuses, tuberculeuses) occupent la peau, mais par suite d'un traitement repercussif ou par le fait des change- ments organiques operes par I'Sge eUes se portent a 1 interieur, sui- les muqueuses et engendi-ent les angines et les bronchites clu-oniques lemphyseme, Tasthme, la gastralgie, la diarrhee, la dyspepsie, le flux vaginal et une foule de maladies chromques. Eerwtisme—'''La. constitution de certains sujets favorable _au developpement des darti-es ou des maladies internes dues au pi-m- cSe dartreux, est ce qu'on appeHe herpeUmne C'est diatbese produit a i'ext^rieur sur la peau, des vesicules, des pustules, des ^uames, des buUes et a I'interiem- des catarrlies muqueux chromques d' ou resiJtent un grand nombre de maladies viscerales .gi'aves X est de natvn-e dai;treuse ^ Amsi on dit qu im individu affecte de dai-ti-es est attemt de la diathese l^ei-petique The words dartre, tetter, and dtter are all supposed to be derived from thTtremulous' or twitching movement to whadi ^^m Jseases sometimes oives rise. They seem too vague to be made the basis ot a SeTs S can only be foiWated as a negation (see dartre. Sve)! burwhich is so comprehensive that it includes nearly aU skin ""iT'cit. p. 1.59. ^ Ibid. p. 165. • 3 Op. cit. p. 18. GRANULAR PHARYNGITIS. 31 those using the voice, such as the clergy, singers, hawkers, and costermongers. In almost every instance the evidence of constitutional delicacy is well marked, and most of the patients present an anfemic appearance. In nearly all cases where the origin of the aifection cannot be attributed to over- use of the voice, the immediately exciting cause is exposure to cold. A series of three successive causes can thus be laid down as being in most instances concerned in producing the disease, viz. : — 1. Constitutional predisposition (this includes any cachexia, but especially the strumous diathesis) ; 2. Over- exertion of the voice (-with consequent weakening of the mucous membrane of the throat) ; 3. Exposure to cold — the latter being the most immediate, though not the most potent, of all the causes. In addition, the application of any irritant to the already weakened mucous membrane is capable of exciting the morbid action of the glandular apparatus. My own experience does not, hoAvever, coincide with that of G-reeni- and Gueneau de Mussy^ with respect to the use of tobacco. It is possible that, in certain persons, excessive smoking may cause congestion of the mucous membrane of the throat, and sometimes tend to produce a blocking up of the mouths of the follicles, but the abuse of tobacco more often leads to simple chronic relaxation. It has been asserted that those who are compelled to breathe constantly a tainted atmosphere, or to reside in a damp climate, are, cceterib- 2xmlnis, most liable to be attacked by this malady; and that those who are subjected to the presence of irritating gases or powders in the atmosphere, as is the case in chemical works, metal factories, cotton mills, coal mines, &c., are prone to the disease. I have met with many cases in which the etiology could not be arrived at. Symptoms. — Patients affected Avith follicular pharyngitis do not as a rule experience any painful sensations at the outset of the disease. The first symptoms are generally confined to a sense of stiffness and dryness in the throat, and a tickling cough. Should the patient, however, be subject to severe fits of coughing, he almost always complains that "it hurts l^im to coiigli " ; and, on questioning him more closely, it can be ascertained that each impulse of coughing causes a feeling of tenderness and soreness about the upper part of the larynx and the arch of the palate. Amongst public speakers or singers the first symptoms which attract the attention of the patient, and generally occupy his mind to th« exclusion of all ' Op. cit. p. 174. •- Op. cit. p. 28. 32 DISEASES OF THE THROAT AND NOSE. Other plienomena attendant on tlie disease, are hoarseness and a loss of power over the voice. As the morhKl con- dition of the foUicles increases, their functions are inter- fered Avith. Dryness and soreness of the throat supervene, causing the patient great inconvenience, and constituting what has been called pharyngitis sicca. An insupportable sense of pricking and heat is often felt in the pharynx, whUst a harsh, dry cough, accompanied by repeated hawking efforts, simulates pulmonary phthisis. The larynx almost con- stantly feels obstructed, and the sufferer is led tomake continual fruitless attempts to clear the throat. Small quantities of viscid mucus are occasionaUy expectorated, Avhilst the strain of excessive coughing sometimes causes the sputa to be tinned with blood. In the most pronounced cases of granular pWn^itis the diseased condition of the foUicles extends tQ the naso-pharyngeal space and posterior nares, to the iront of the soft palate and uvula, and to the upper part of the larynx and oesophagus. As a consequence, therefore, of the implication of these parts the malady is sometmies accompanied by impairment of the senses of hearing, smell, : uUas " n pJopoition as the orifice of the Eustachian tube the pituitary membrane, or the mucous covering of the palate mrtkipate in the morbid process. Hoarseness and feebleness of voi e result from the larynx being involved, and he general soreness and stiffness of the parts concerned in the mXtion of speech cause a marked hesitation and effort m S lation. When the upper part o the esophagus or tTl^lotti. becomes affected considerable pam m swaUow- in'usuaUy results, and some patients are reduced to the neceTsity 'of subsisting altogether on M-'^^ ^h^ symptoms are, as a rule, much more marked m the e^^^iftiAe thSi hr the hypertrophic, form of the disease. As Pe er ^ remarks however, a considerable amount of enlargement of r » of the pharynx, &c., may ^l^^^Zl time, give rise to -^f -J-^brr be quite unconscious oi tnere umuo j o 1 " Diet, des Sciences Med." vol. iv. p. /49. GRANULAR PHARYNGITIS. 33 raay be seen to be dotted "udth small elevations, about the size of a millet-seed, entirely isolated from eacb other. As the ilisease advances, these gi'annlations increase in number until they become packed so closely together as to give a reticu- lated appearance to the part, and finally they coalesce and form broad, flattened elevations, or long ridges running in various irregular directions over the mucous membrane. In most cases injection of the superficial veins of the pharynx is present, and these vessels can often be seen pursuing a tortu- ous course along the fiurows, or forming a kind of net-work round the elevations. As the disease advances the granulations become developed on the adjacent parts of the fauces and tonsils, and sometimes give rise to hypertrophy of these glands. Examination by means of the rhinoscopic and laryngeal mirrors will be required in order to estimate how far the naso-pharyngeal cavity, the lower part of the pharynx, and the larynx are implicated in the morbid process. Coincident with the appearance of these several phenomena there is always considerable perversion of the secretions of the pharynx. This derangement is almost always on the side of deficiency. In the exudative form of follicular disease, the affection generaUy commences in the tonsils or in their immediate neighbom-hood, and advances to the posterior wall of the pharynx, the back of the tongue, the epiglottis, and the in- tenor of the larynx. In health the secretion of the follicles appears to the naked eye as a watery transparent fluid, but if the follicles become acutely inflamed their secretion (probably from mcrease of the corpuscular elements) becomes milky in ■colour and consistence. This condition is constantly seen in folhcular tonsiUitis. If the inflammation is less acute and more persistent, the mUky secretion becomes inspissated, and leads to the formation of the caseous deposits so characteristic ot the disease. In the earliest period, the throat is seen to be c ry and gHstening, whilst the orifices of the foUicles are bright red, and the intervals of mucous membrane between tiiem generaUy slightly hyperajmic. Later on, however, the diseased follicles discharge a morbid secretion, and viscid mucus is often seen adhering in patches to the follicles, or Mling up the intervals between them. On pressing the en- larged follicles this exudation may be seen to issue from them, generally by a single, minute aperture, situated near the centre of the elevation. The secretion may have the cheesy character already described, or may resemble the D 34 DISEASES OF THE THROAT AND NOSE. ir;4L . seen ^i^^** ^olS.^^ Ld oiorn, ckcomposmg -^-j^f^, ^^^^^^^^^^ experience, "^^''^''T "LXTsease of the phavj'^'^. »<1 direct """^^uence ot M^^^^^^^ i .%*cietp:W4err^^^^^^^^^ SSch calcareous matter cordd be pr«=«* ™' * leW to stated in and about the ton,rU.;<'»"'| Jthoth S» n the exudative form of the ^ that writer's «-P«»™ V • "r£™ 3 A SnS -k'^^'™ in thrs country and m Gennan^^^^^ t^^ and loss ot tone oi au lue Tjecomes in some results from '^e disease and the X'"^^,, „, tte :atis':ne1fte=o::sVf^rin^Ll— no the incessant, tickling congh. . , • ^ tLis affection , considers dceratio. .s f«,«e.t, Op. c.t. pp. 51-lSO et seq. . : ^UJ-:'zSssen'B •< Cyclopedia " (Gei-man edition), vol. vu. part I. p. 266. . , , , n-een in which stifEocation neflriy oc- ^ * See a case depicted by Dr txreenm w ^^^^ ^^.^^ ^^^^ curred on several o'^^a^^?^^^ Op cit. p. 270. iuto the larynx during mspuation . up. e GRANULAR PHARYNGITIS. 35 generative changes in glandnlfe jDrevionsly hypertrophied, or -whether the exudation is the product of a simple morbid secretion is at present unknown. The nature, differences and extent of the morbid alterations in the mucous membrane and its secretory glands have yet to be elucidated, but the tendency of investigation is to show that the hypertrophic and_ exudative diseases, though they may co-exist, are totally distinct affections, differing in their symptoms, course, and pathology, and requiring, as is shown in this article, totally different treatment. According to Stoerk,i in the Injpertropldc fonn the granulations consist of large, nearly round, swollen, epithelial cells, the layers of hard compressed cells or flattened scales which usually cover and protect the surface having disappeared. The morbid changes are in fact more in the epithelium than in the follicles. In a case of exudativp disease reported by de Mussy,^ where a microscopic examina- tion was made by Drs. Sappey and Eobin, the principal liistological changes noted were as foUows :— The tubules of the foUicles were found considerably enlarged, both as regards the diameter of their cavity and the thickness of their walls. In the follicles which were most hypertrophied and indurated, small calcareous concretions were discovered composed principally of carbonate of lime. In some of the glands these concretions were numerous, and packed together so closely as to present when detached a crystaUine appearance, owing to their surfaces having been moulded into polyhedral, facetted figures. On the other hand, the ceHular tissue connecting the secretory tubides and the epitheHum Jming then: internal walls presented but little departure from the normal condition beyond a very slight thickening. With respect to the vessels of the hypertrophied follicles, the capillaries showed no perceptible change, but on the whole the diseased glands appeared to be less vascular than in the healthy pharynx. The cheesy secretion consists of the cUhris of epithelial ceUs, of molecules, and oil globules. Diacinosis.—T\i^ recognition of follicular pharyn-itis whether hypei;trophic or exudative, presents no difficulty' and the condition can scarcely be confounded with any other disease. In cases where the cheesy exudation is very abundant and coats the surface of the pharynx, a person p. \x^^^^ KranUieiten des Kehlkopfes." Stuttgart, 187fi • Op. cit. p. 87. 36 DISEASES OF TUB TnROxS.T AND NOSE. Who had never seen an example of either ^^^ff ;;2^S^^/^^^^ pose that diphtheria WHS present. As a ^'f^^' ^^^/J^g^^^ discharge in the follicular disease adheres to the surtace ot he memhrane^ small Mated patches and is very ^j^SeXt tTthe tough, Inrhranous, exudation which occux-s in the more serious malady. . nf PmimsU.-l rannot at all acquiesce in the "p nion of T)r Greenl that pulmonary phthisis can ever owe its origin ?o granX p Wis. lor is it more likely "n Ac folKcles of the esophagus hecome ^plicated m J-^ect action, ina^nant disease ^^^^^^^ ZS^.^^:^^^, ^X'grSrph"' Most eases o^^tenf iT °a tip i^harvnx "et well under appropriate treatment ^.e., as n.Jhe trouble sensations are concerned, but mth Aspect to the W function, the prognosis is not always so S/olhle, especially as regards public ^1-^ers ^ng^ t^^^^^^ if the disease has existed many years The vocal or an is I i i^VpIv to remain permanently weakened, at least extremely likely to i^mam p« j constant pro- the affected pari!! is the '^f'--'''}^'-°]-,Z lt&^rn^ a two forms of the disease as descr*«l m different method of '»P'>»1 '^^^'^^''^''^.a "^^^^ productive tmpUc fo,in alone IS If '''f ' ""J'T^o^t Ho 1>. Phar.). of '-'^'L'ldd L afplTecl^^^^^^^ This caustic should Wieii .,..,„ti^„. and in some rately, but only « ajj^^ ° tucM on ihe same day. SratiS"of *at r;mall V-ity of the 2 Ibid. p. 129. . , 1 Op. cit. p. 118. ,,ri^^.„PTirlium der praktisclieu Medicm, ■ 3 sL alBO K;--p' Sl'^x T^^^^^^^ vol. i. p. 500; and p 218; Niemeyer: iamuiuo^ Wendt: Op. cit. p. 278. GRANULAR rHARYNGITIS. 37 caustic is applied to the desired part -with the pharyngeal spatiila (page 9). Immediately after the application has been made the patient should he directed to gargle and wash out the throat with cold water, so as to remove any particles of the caustic that may remain adherent to the part touched. The London paste should he per- severed with in this way until all the granulations are destroyed. As a rule, one touch of the paste is suffi- cient to remove a granulation, and establish a healthy action in the part ; but if the elevation be very large, or if there be many separate raised spots, a number of appli- cations may have to be made. It is scarcely necessary to observe that it is most important not to set up extensive inflammation by using the paste too freely on any one occa- sion. In some persons the application may be made every day, whilst in others twice or three times a week will be sufficient. In the intervals milder remedies can often be used advantageously — such as the jiigmenta of percliloride of iron or chloride of zinc (Throat Hosp. Phar.) ; and when there is much irritation of the fauces, consequent either on the disease or on the action of the caustic, a sedative inhalation of Benzoin or Hoi^ (Throat Hosp. Phar.) is beneficial. It has been recommended that the elevations should be destroyed bygalvanic,i or actual,- cautery ; but as the granu- lations can be readQy got rid of by a simple escharotic, com- plicated processes and alarming methods had better be avoided. As regards the exudative form of follicular pharyngitis the local treatment can be carried out without having recourse to so strong a caustic as the London paste. My practice in such cases is first to scrape the mucous membrane where- ever the white spots appear with the " pharyngeal curette," already described (p. 10), and having thus cleared away the secretion to apply the solid stick of nitrate of silver — Avhich should be carefully pointed for the purpose —to each spot which discharges an abnormal secretion. Whilst the local treatment is being accomplished, internal remedies calculated to give tone to the vital powers, and improve the general health of the patient should be ad- ministered. Struma, anoamia, syphilis, &c., must be met by the exhibition of cod-liver oil, iron, iodide of potassium, &c. After the topical measures have been completed, the per- 1 Michel! : " Deutsche Zoibschi'ift flir Cliimrgie," ii. Bd. 2 Heft. ^ Foulis: " GLasgow Med. Jomii." October, 1877. 38 DISEASES OF THE THROAT AND NOSE. maneucy of the cure may usually he established by change of air, residence at the seaside for a month or two when the season is suitable, or by directing the patient to use the arsenical waters of Mcnt Dore, the hot sulphur springs at Aix-les-P.ains, Cauterets, or Weilbach, or the saline waters of Ems. By a course of mineral waters and sprays the local Aveakness" and diathetic condition are both generally greatly ameliorated. In the case of strumous childi-en, benefit often results from a stay at Woodhall Spa, whilst the bracing air of Harrogate, Tunbridge AVells, and similar places often proves invigorating. PUTEID SOEE THEOAT. Latin ^J^/.— Cynanche maligna. Angina putris. French Eq.—AxigiuQ gangreneuse. Angine maligne. German ^g.— Angina Maligna oder Gangrajnosa. Italian Eq. — Angina maligna. Definition.— PrMJiiYiue gangrene of the pharyngeal mucous membrane, constituthui an affection per se, and originating mdepenclently of any other malady, such as dijMhena, scarlet fever, Sfc. History— As Peter ^ weU observes, the history of this affection may be divided into tlii-ee periods. _ Eirst, the ancient period, when a belief, founded principally on the vacrue descriptions of Hippocrates and Areta^us, prevailed that the disease was a common one, whilst in fact abnost aU the reported examples were cases of diphtheria. Secondly, the period of Bretonneau, subsequent to 1821, when the re- searches of that observer proved that the so-caUed cases of cran-rene were only instances of diphtheria, and that a true San°renous lesion was rarely, if ever, present m that disease. As a consequence of this discovery a majority of the pro- fession were led to affirm the non-existence of a primitive gangrene of the tlu-oat. Thirdly, the contemporary period in which, owing mainly to the observations of Gubler- and TroIsseau> the%xistence of the malady has been clearly recognized, whUst the conclusion has been arrived at that the disease is an extremely rare one. Miology.— Malignant sore throat appears always to be the 1 "Dict. des Sciences Medicales." Paxis, 1866, vol. iv. p. 700. 2 « Archiv. Generales de Med.'' 185(, vol. ix. 5 3 3 " Clinique Med. de I'Hotel-Dieu." Pans, ISbo, p. 324. PUTRID SORE THROAT. 39 result of Llood-poisoning. It sometimes commences as a severe inflammation, which quickly leads to gangrene ; whilst at other times it is gangrenous from the commence- ment. I have met with several instances of the inflam- matory form, but only one case in which gangi-ene was the initial local manifestation. Trousseau remarks that " It has for its fundamental character mortification of the mucous membrane of the pharynx, which takes place at the first onset of the malady, and occasionally spreads to the cheeks and lips. The disease is comparable to gangrenous stomatitis." Sijmjjtoms. — In some instances sthenic phenomena, with, considerable fever and local inflammation, indicate the ad- vent of the malady, but in most cases the symptoms are adynamic from the first. A premonitory stage is not always jDresent, and soreness of the throat rapidly becoming intensified is often the first symptom which disturbs the feelings of the patient. The gangrene frequently supervenes with great rapidity, so that in two or three days a portion of the pharyngeal mucous membrane may be sphacelated. In some cases there is considerable swelling of the cervical glands, but this lesion is not invariably present. As the morbid process becomes fully develojjed, it is in all instances accompanied by a remarkable prostration of the vital powers. A state of collapse comparable to that which occurs in cholera indicates the intensity of the blood-poisoning ; there is great loss of body heat, and the pulse soon becomes slow and in- frequent. Thus in one of Gubler's^ cases the contractions of the heart sank to fifteen per minute. The extremely feeble condition of the circulation is shown by the paUor, coldness, and bluish discoloration of the skin, especially of the extremities. The expression of the face is strUdngly altered and pinched. The patient generally dies from syncope, the intelligence often remaining intact to the last. In some cases, however, the sufferer becomes coma- tose, and occasionally symptoms of profound lesions of the thoracic or abdominal viscera are manifested. Should the lungs be affected copious hajmoptysis results ; whilst, if the gangrenous process invades the alimentary tract, an abundant, fetid, diarrhoea supervenes, which all remedies are powerless to check. Occasionally a general tendency to hsemor- rhage is manifested, and a persistent bleeding occurs simultaneously from the lungs, bowels, nose, mouth, and ^ Loc. cit. p. 518. 40 DISEASES OF THE THROAT AND NOSE. even under tlie slcin, which becomes covered with petechue,. and ultimately sphacelated at the points of ccchymosis. Trousseau saw diplopir and phlebitis of all the superficial veins about the end of the third week. Sometmies Oidema of the glottis quickly proves fatal to the sufferer, and I have treated three cases of this kind in which tracheotomy proved oidy a temporary palliative. Throughout the disease the odour of the breath is so extremely fetid that it is alone often sufacient to enable a practitioner who has once pre- viously seen a case to diagnose the disease as soon as he enters the room of the patient. When, however, the gangrene is of very slight extent, this symptom may be absent. On inspecting the pharynx in the first stage of the disease the appearances are generally by no means characteristic ot the approach of so serious an affection, although the peculiar foul smell of the breath may be quite perceptible. As soon, however, as the process of gangrene has commenced the- back of the pharynx, the pillars of the fauces, and the tonsils can be seen covered with discoloured patches— sometimes almost black, which are slightly elevated above the surrounding surface, and forming eschars idtimately detach themselves from the tissues beneath. TJlcerations variable in extent and depth, residt from the separation ot the sloughs. In the worst cases the disease makes constant pro-ress in the direction of the mouth, the cesophagus and the°air-passages, and terminates its onward course only by the death of the patient. Typical cases of this disease have been described l)y G-ubleri and Trousseau; 2 and Eilliet and Bavthez3 have re- ported some instances as occurring in chddren binder fiA^e Vears of age. Some of these foUowed an_ attack of scarla- tina or measles, and do not belong to the diseases now under consideration, but others were evidently examples of primitn e °Tr4-At"^^^^^^^ of putrid sore throat prove fatfl Zortunities of studying the morbid anatomy of the. ^^Z. from time to time. In ^l-e -s^^^^^^^^^^ the -an<.rene is circumscribed, patches of an o^ al oi cue a B W from one-twentieth to half an inch m diameter are found on the mucous membrane of the pharynx, and frequently on , _ ., 2 Loc. cit. 1 Lioc. cit. , ^ , -.T--, " S I'' 1841, p. 446, et seq.- 3 " Arcluv. Generales de ^f^X /^•g^'.r'is'fi^o, ild series, t. ."ii. Tor other cases see Musset : JJ^°'^Jl Vo^q „ 170 p. 4 36 ; aiid Bouchut : ' ' Gazette des Hopitaux, 1 808, p. 1 - u. PUTRID SORE THROxVT. 41 the epiglottis aud upper part of the laiynx. Tlie surface of these patches, after death, is depressed, and their colour varies from a dark grey to an absolute black. The edges are perpendicular, and of dii'ty yellow colom-, and the morti- fied structures exhale a gangrenous odour. The process of destruction is generally confined to the mucous membrane and sub-mucous tissue. The beds of muscular fibre are laid bare, but their substance is usually intact, though sometimes; softened. "When the eschar has faUen off, the resulting ulcer has occasionally been observed to be covered -with a delicate false membrane. In the worst examples of the disease the sphacelated patches can be noted in the larynx,, trachea, lungs, oesophagus, and throughout the alimentary tract. Diar/nosis— The peculiar gangxenous odour is sufficiently characteristic to enable a person who has once smelt it tO' recognize at once the presence of the mortifying process. Diph- theria is the only disease that can be confoimded with putrid sore throat, but the resemblance is not sulficiently great to lead an observant practitioner into error. The greyish black patches in the pharynx may exist in both diseases, but in diphtheria they are at first whitish and gradually become darker, whereas in true gangrene the diagnostic appearance is present from the first moment that the eschars begin to form. In diphtheria the sub-maxiUary and cervical glands frequently become much sAvollen a,t the outset of the disease, but in putrid sore throat these parts in some cases remain altogether unaffected, whilst in others, the tumefaction is but slight. The fetor of the breath in diphtheria is not very perceptible at first, but gradually in- creases as the disease becomes developed. In putrid sore throat the distinctive gangrenous odour is present at the onset of the malady, and frequently even before inspection, can detect any considerable lesion in the pharynx. Prognosis. — As putrid sore throat is only a local mani- festation of a profomid blood-poisoning, the prognosis is necessarily extremely grave. But few cases of recovery are^ on record, and in most instances the patient has been carried off in a few days. Trousseau,^ however, saw a case which ultimately did well, and the example related by Musset^ also terminated in recovery. I have met with two cases which recovered, and three, aheady referred to, which proved fatal. 1 Loc. cit. 2 Loc. cit. 42 DISEASES OF THE THEOAT AND NOSE. Treatment. — Active measures are iBiperatively demanded in the treatment of putrid sore throat. Trousseau and Gubler had recourse to apphcations of strong hydrochloric acid, in order to destroy the diseased tissues, but, keeping in view -the general nature of the malady, little can he expected from topical medication. Sedative and antiseptic gargles and sprays are the most suitable local remedies. Tor this purpose borax, myrrh, bromide of potassium, and perman- ganate of potash may be employed. The most important indication, however, is to gain time, and if possible support the vital powers until the phenomena of the blood-poison- ing have passed away. With this view quinine and bark should be administered every three or four hours, and stimidants freely given. In the case successfully treated by Musset perchloride of iron— about 30 gi-ains in the twenty- four hours — was given. "Whatever drugs are chosen, the diet must be of the most concentrated and nutritious description, and strong beef tea, eggs beaten up with brandy, &c., must be administered every hour or two. Nutritive enemata, such as are recommended in the article on " Stricture of the CEsophagus," shoidd also be had recourse to, when the_ con- •dition of the throat interferes to any extent mth deglutition. HEEPES OF THE PHAEYNX. Latin Eq. — Herpes pharyngis. French ^g.— Angine herpetique. Herpes guttural. German iJ^.— Herpes des Schlundkopfs. Herpetische Angina. Italian ^5-.— Erpete della faringe. Definition.— eruption on the mucous membrane of the jjharynx running an acute course analogous to that of herpes when appearing on the sMn. Miology.—^^VO^^^^B to cold appears to be the principal cause of herpes of the pharynx. According to Gubleri the disease is a kind of eruption in the throat, constitutmg as it were the crisis of a fever a frigore. On this account it is most frequent in cold, damp climates, and at those seasons of the year when sudden changes of temperature and mclement weather prevaU. In England it is a rare affection, and all 1 "Memoire sur I'Herpes Guttural," &c. "Union M^dicale," January, 1858. HERPES OF THE PHARYNX. 43 the cases I have met with have occurred in the spring or autumn. I have met with one case in which the disease attacked a child three years consecutively — the left side of the palate and wall of the pharynx being the parts affected on each occasion. Women, children, and delicate persons are most liable to the malady, owing doubtless to their being more easily overcome by cold. Feroni thinks that mental emotions have the power of determining an attack of herpes of the pharynx ; whilst Bertholle - believes the affection to be often associated with some uterine disturbance, and states that it is most frequently seen in females at the menstrual periods. Peter^ considers that the contact of irritating sub- stances with the pharynx, such as hot condiments, and acrid, fetid, or miasmatic exhalations are often productive of the disease. J^inally, Trousseau'* has shown that herpes of the ])harynx prevails to a great extent during epidemics of diphtheria, and that the herpetic eruption may resolve itself into diphtheritic patches, leading ultimately even to a fatal termination. Symptoms. — Herpes of the pharynx is always ushered in by a premonitory stage of general malaise, and symptoms of pyrexia. In a period varying from a few hours to two or three days the patient experiences a sensation of soreness and heat in the throat, which is greatly increased by swallowing. In most cases the local malady provokes considerable saliva- tion. The disease runs an acute course. After four or five days the subjective symptoms diminish greatly in intensity, and at the end of a fortnight the parts usually regain their normal condition. On inspecting the pharynx at the outset of the disease, a variable number of single or grouped whitish, opaline, vesicles can be perceived. They usually occupy the soft palate, the piUars of the fauces, and the tonsils, and at the apex of each vesicle there is often a dark spot. The mucous membrane forming the base of each vesicle or group of vesicles is always inflamed, and presents a red, tumefied appearance. The number of vesicles varies greatly in dif- ferent cases. Sometimes only one or two can be seen, whUst in the worst instances they are arranged so closely ' "De I'Angine Herpetique,"—" These cle Paris," 1858, No. 219. - "De I'Herpes Guttural," &c. &c. "Union Med." t. xxx. 1866. ' "Diet, des Sc. Med." Paris, 1864, vol. iv. p. 715. * "Clin. Med. de I'Hotel-Dieu." Paris, 18C6, vol. i. p 307. et seq. ' 44 DISEASES OF THE THROAT AND NOSE. together as to become confluent. As Stevenson Smitli^ remarks, the soft palate is occasionally so sprinkled over witli minute vesicles, of the size of tlie head of a pm, that it- appears as if it had been dusted Avith white pepper, ilie duration of the vesicles is ephemeral ; their existence varies _ from twenty-four to forty-eight hours, but in many cases they appear in successive crops. As the local morbid action pur- sues its course, the termination of the vesicu ar stage may take place in three different ways. In the mddest cases the vesicles disappear by reabsorption and leave no lesion to mark their former situation. In another variety of the disease the vesicles burst and a small circular ulcer results which appears deep, owing to the tumefaction of the mucous membrane. In a day or two these ulcers cicatrize, the n- liltration of the adjacent tissues is resolved, and the part resumes its normal condition. In the thud and severest form of the disease rdceration takes place, but the sore, instead of healing, becomes covered by a false ^lembrane resembUng, both in appearance and structure, the exudation of diphtheria. These phenomena most commonly occui on the palate, and are rarely seen on the PO^teriOT waR of the pharynx. When the vesicles are very ^^^^^^^Jf^ patches of exudation may unite at some places, ^^ i" ■ sheets of false membrane of limited extent In three or fou day , however, the idcers heal, the exudation becomes softened apd detached, and the mucous membrane recover, ts Shy state. In some cases the larynx or the orifices of t Eustachian tubes may be the seat of ^or^^^ vesicles. The respiration and hearing ^^y,^^^.. ^^^^^^^^^^ affected, but serious symptoms are seldom met with. Simul taneousiv with the outbreak of herpes m the throat, the same eXt on ^ay manifest itseK in the mouth or on the hps, S affordin- a clear indication for the diagnosis of the Sdf CerW idiosyncrasies have ^^^.een^^^ patients liable to suffer from this affection. Thus -Lf^iaieu dentins the case of a young man, ^:^ora her^J^ Xrvnv alternated for several years with a similar eruption oS to^rsu^^^^ of the prepuce. Other instances have existence of the pharyngeal affection.-^ . ^Edin. Med. Jouin.." Nov 1863. ''/^^^^ ^JJ^*^-'^^ HERPES OP THE PHARYNX. 45 PatJwlogy. — The consideration of the pathology of herpes "belongs to "the department of the dermatologist, and it is therefore unnecessary to enter here on a question which is fully treated in the text-books on skin-diseases. Suffice it to say that the malady is believed to depend on a defect in the innervation of the part brought about by exposure to cold. In addition, Gubler i has shown that the morbid action Avhich in herpes causes the formation of crusts on the skin, may give rise to the evolution of a false membrane when the disease attacks mucous surfaces. Diagnosis. — Herpes of the pharynx can only be confounded Avith diphtheria, and it is not possible in all cases to dif- ferentiate the two diseases with certainty. If the case is seen during tlie vesicular stage, nothing can be more easy than the recognition of the malady ; but at a later period, in severe instances, when the pharynx has become the seat of several patches of false membrane, the most experienced practitioner may be deceived as to the nature of the disease. According to Peter ^ the diagnosis of herpes of the pharynx at this stage can only be deduced from the existence of one ■or both of two phenomena — viz., (1) the presence amongst the patches of exudation of small ulcers such as are commonly consecutive to the rupture of the vesicles, and (2) the ap- pearance of smaU isolated spots of false membrane, the transparency of which indicates their recent formation, whilst their size and circular shape leads the observer to suspect the previous existence of a vesicle. The coincidence of a herpetic skin eruption with a doubtful throat affection materially assists the diagnosis, although the occurrence "by no means affords conclusive evidence as to the nature of the internal malady. In the absence of all the distinctive marks mentioned above it is sometimes impossible to arrive at a definite opinion, and under these circumstances the case had better be treated as one of diphtheria — an error in that du'ection being least likely to lead to any evil results. Prognosis. — Sporadic cases of herpes of the pharynx may be pronounced to be devoid of aU gravity. Wlien, however, the disease manifests itself during an epidemic of diphtheria, the observations of Trousseau, as to the probabiUty of the milder affection becoming metamorphized into the more serious malady, must be borne in mind. Treatment. — As the onset of the disease is generally ac- companied by considerable fever a diaphoretic or febrifuge ' Loc. cit. - Loc. cit. p. 716. 46 DISEASES OF THE THROAT AND NOSE. medicine is often serviceable. In Wo cases I found tincture of aconite rapidly relieve the symptoms, and, in the case already referred to, of a child very subject to the disease, the internal administration of arsenic always rapidly effected a cure. The local pain must be met by the use of emollient and sedative gargles, and hot, soothing, inhalations, such as the Garg. Boracis, Garg. Pot. Brom., Vapor Benzoini, and the Vapor Lupuli, etc. (Throat Hosp. Phar.) ; or by the in- safaation of starch and morphia (gr. {-), once or twice a day. In the last stage of the malady when the patches of exuda- tion are becoming detached, the fetor of the breath calls for the employment of antiseptic gargles, of which permanganate of potash in solution is the most effective. EHEUMATIC SOEE THROAT. Latin Eq. — Angina rheumatica. French Eq. — Angine rhumatismale. German Eq. — Ptheumatische angina. Italian Eq. — Angina reumatica. Definition. — An affection of the throat occurring inxoffrsons^ of rheumatic constiiution, characterized hy suddenness _ of attach, severe pain, and the local appearances of inflammation. TJie sijmptoms are fugacious, and frequently give place to some local rheumatic manifestation, szich as torticollis, hmibago, or sub-acute aiiicidar inflammation. Etiology. The poison of rheumatism is the precise cause of this affection, but its outbreak is generally due to exposui'e to cold. Persons who have had frequent attacks of simple inflammation of the pharynx or tonsils are liable to this form of sore throat should they at any time become the subiects of the rheumatic diathesis. Symptoms.— Th.Q symptoms of rheumatic sore throat have been so weU described by Trousseau i that I cannot do better than employ his words. "An individual," he observes, "subject to rheumatic pains takes cold. At the end of a few houi^ he experiences an extremely acute pain m the tlii'oat, so that he can scarcely swallow a drop of water, nor even his sahva, the dedutition of these small quantities of bquid causing much mo°re suffering than that of an alimentary bolus. On examm- 1 " Clin. Med. dc rHotel-Dieu." Paris, 1865, t. 1. p. 332. RHEUMATIC SORE THROAT. 47 ing the tliroat tlie interior of the jDhavynx and the veil of the palate i:)resent a redness more or less pronounced. The uvula invaded hy the inflammation is osdematous and elon- gated. All these phenomena are going to disappear with great rapidity, hecause they are fugacious, lilce most affections of a rheumatic natui-e. The next day the acute pain of this angina will have ceased as if by enchantment, at the same time that another pain will occupy the neck, producing torticollis ; whilst the day after, one of the shoulders may be the part attacked. Again, another day, and the patient will complain of lumbago. As to the angina, its duration may vary from twenty-four to forty-eight hours. It is because they have had to deal with these rheumatic sore throats that the physicians to whom I have referred have been enabled to boast of having gained the power of averting incipient in- flammations of the throat. Patients who have hacl several attacks of this kind of sore throat are able at the outset to distinguish the rheumatic affection from a veritable phlegmo- nous inflammation ; but the physician cannot differentiate the two maladies in the first moments of their appearance." In many rheumatic patients the throat affection is an in- variable precursor of a general attack of sub-acute rheumatism. Diagnosis — This affection can seldom be diagnosed at its outset, unless the practitioner has observed similar previous attacks in the same person, but, as remarked by Trousseau, the patient himself is often able to distinguish by his sensa- tions the rheumatic nature of the affection, if he has suffered before in the same way. The sudden disappearance of the angina, and the development of unmistakeable rheumatic symptoms in some other part of the body, is of course decisive. Prognosis. — The sore throat of rheumatism is the least serious of any of the local manifestations of that disease, and the only gravity attached to the prognosis depends on the possibility that in the resolution of the angina the malady may select for its seat some more vital part. Treatment — The acute pain of the disease is best treated by the use of emolbent and sedative gargles, whilst at the same time warm poultices, or spongio-piline, saturated with tincture of opium, may be applied to the neck externally. Constitutionally the specific remedies that are supposed to neutralise, or cause the elimination of, the rheumatic poison such as bi-carbonate of potash, iodide of potassium, salicylic acid, &c., should be administered. 48 DISEASES OF THE THROAT AND NOSE, Gouty Sore Throat. In connection -with rheumatic sore throat it may here he stated that there is also a species of angina dependent on "onti I have met with several well-marked instances. In °one case a gentleman who frequently suffered from attacks of angina became subject to gout, and was never acrain attacked with inflammation of the throat. In_ another case the patient was suffering from acute pharyngitis, when the symptoms suddenly disappeared, and an acute attack of gout developed in the great toe of the right toot ; after three days the gouty inflammation of the toe disappeared, and acute hypereemia of the pharynx supervened. Dr. I'rosser James2 caUs attention to the rarity of the acute affection, thou'Th he thinlcs that the mucous membrane of the throat is prone to chronic inflammation in those of gouty constitution. The treatment should be conducted on the principles recom- mended for rheumatism, with such modifications as the •different diathesis may require. TONSILLITIS. (Synonyms : Quinsy. Cynanche Tonsillaris.) Latin JJf/.— Inflammatio tonsiUarum. French ig.-Esqumancie. Amygdalite. Angme tonsdlau-e. German i^.-Angina tonsiUaris. Amygdalitis. Entzundung der Mandeln. Italian Eq.—Aj^gmn tonsiUare. Tonsilhtide. Definition.— ^czjfe inflammation of the tondls,^ which mav he of superficial character, or extend deeply ^nto tlie ZrenchymatoL mhstance, and may termmate m resolut^on, ahscess, or chronic enlanjement of the glands. ^^,-,^or/v -The causes of tonsHlitis may be divided into 1 -'n PxcUina Amongst the former, the greatest predisposing and ; ° ^^^^ disposition to the S ron bSween 15 and 20, reaching its ~^2XlZ 20 and 25. The disease is seldom seen m chiidien Deioie , „ -r. X -ni-Q^Prt de Anjnna Arthritica," tTpsal, 1793 ; .-Sore Ttaoat." Chv^chill, 1878, p. 120, ,t se,. TONSILLITIS. 49 the fiftli year, and is equally rare in adults after middle age — scarcely any cases occurring after 50. The following table of 1,000 cases treated by me at the Hospital for Diseases of the Throat illustrates the influence ■of age : — • Under 10 years . . . . , . . . 35 10 to 15 16 to 20 20 to 25 25 to 30 30 to 40 40 to 50 50 to 60 60 to 70 36 184 / 323 1 219/ 220 542 143 51 9 nil. This table shows the sudden and remarkably increased proclivity to the disease soon after puberty ; for whilst from 10 to 15 years of age there were only 3.6 cases, from 15 to 20 there were 184, Again, it illustrates the fact that quinsy is more common between 20 and 30 than at all ages put together. The sudden fall after 25 is also remarkable. It ■\vili be noticed that young children are very little subject to the disease — an immunity which is all the more ciuious, when it is borne in mind that chronic enlargement of the -tonsils takes place in 26-5 per cent, of cases in the first decennium. In the 1,000 cases tabulated above, 597 were males and 403 females. Enlargement of the tonsils, congenital or acquired, renders the individual prone to attacks of tonsillitis, and a person who has once been affected with the disease is very liable to have a second attack if at any time he should take •cold. This rule holds good to such an extent that in some patients the tonsils, after repeated inflamma- tions, seem to constitute a veritable locus minimce resist- entue. Under these circiunstances these glands appear to sympathize with every irregularity of the body, and an «rror of diet occasioning a slight dyspepsia, or a derangement of the _ sexual organs in females, may give rise to an attack of tonsillitis. Constitutional delicacy, especially when dependent on the strumous diathesis, may also be mentioned as pre- disposing to quinsy; whilst the poison of gout and rheu- matism i occasionally seem to favour the production of the disease. The exciting causes of tonsillitis are almost invariably wet J Desnos: "Diet, de Med. et de Chirurg. Prat.," Paris, 1865 Holmes's "System of Surgery," voL 50 ' DISEASES OF THE THROAT AND NOSE. and cold. A surface cl^ cspeciaUy about the headland \,n^t Tn raoDortion to tlie susceptibility ot the attack ofqumsy It is «^ ^^.^ ^^^^.^^^ ':Zf^'Zt::lS:''^^°of tempe^atui-e and inclement "^^i:7^o"eTautunin, is a mistake as xeg^ds^^^^^^ .nini as the following statistics taken from cases treated at spring, as tne louoAA o conclusively show :— 1872. January Pebruary March April May . . June. . July.. August September October . November December 1873. 14 10 9 11 15 13 17 19 43 41 17 11 16 16 9 5 10 8 32 24 20 47 21 5 1874. 1875. 220 105 15 8 12 10 15 16 16 24 51 33 20 8 235 21 17 27 18 30 11 32 25 52 26 22 16 297 Total Mean 1876. No. of monthly Cases. ( )f 6 years. 20 86 17-2 19 70 14-0 7 64 12-8 15 59 11-8 7 77 15-4 22 69 13-8 14 111 22-2 15 107 21-4 39 205 41-0 31 178 35-6 21 101 20-2 9 49 9-8 219 1176 19-6 .. 19-6 montlis (March, . . 13*33 32-26 Mean monthly average . . • Average monthly mean of the three sp] .... Avt?at;SW--n of-ihe ti;;ee autumn months^ (Sept., Oct.*^ Nov.) .. . . it is in December, hut it ^^^^^ ^^^^^ raove likely sulfering from acute in December to go out to a ^-P^^J^-^^^^^^^^ or even March or Apid- P^-^,^, between spring ana ^irra^^^^^ equally inclement in thas 1s^S°=le"p:Sli£^ — in some few instances, but, irom i TOKSILLITIS. 51 there is great difficulty in distinguisliing cases of simple tonsillitis from epidemics of scarlet fever. ^ One instance, however, has been described with such care and precision by Mayenc ^ that little doubt can remain as to the almost purely tonsillar natiu'e of the malady. This epidemic occurred in 1818 at Gordon, in France, and lasted for upwards of five months, attacking males and females, from fifteen to thirty years of age, in almost equal proportion. Inflammation of the tonsils occurs not only as one of the phenomena arising from the specific blood-poison of scarlet fever, but it may also be present in connection with variola or measles. Desnos ^ states that prolonged residence in a very high temperature, especially if the air be vitiated, may produce an attack of quinsy. Ton- sillitis may also originate from the inhalation of irritating gases or from swallowing caustic substances. In such cases, of course, the afi'ection is only a part of a general lesion of the respiratory or alimentary tract. Finally, mechanical causes may give rise to inflammation of the tonsils. The most common of these are wounds, gunshot accidents,* the impaction of foreign bodies in the gland during deglutition, such as a piece of bone, the fragment of a fruit stone, &c. — and the accretions of cheesy or calcareous matter in the lacunee of the tonsils. Symptoms. — The symptoms attendant on inflammation of the tonsils vary, both constitutionally and locally, in propor- tion to the intensity of the morbid action in the part, and hence it is useful to make some division of the malady with a view to the due application of therapeutics. Vidal 5 separates tonsillitis into erythematous and phlegmonous, i.e., superficial and deep, whUst Wagner ^ distinguishes no less than five cUfi'erent forms, viz., (1) simple or superficial, (2) lacunalor follicular, (3) parenchymatous, (4) tonsillitis with abscess in the substance of the gland, and (5) peri- or retro-tonsiUar, abscess. Clinically, however, there is no well-marked line of demarcation between the five varieties enumerated by Wagner, and as regards treatment it is sufficient to make two divisions ° 1 /oA^^'^^'^' ^^'^^^1- (1) superficial or follicular tonsillitis, and (2) deep or parenchymatous tonsiUitis. The inflammation ' Vidal: "Diet, des Sciences Medicales," vol. iv. p. 19: also Desnos : Loc. cit. p. 129. V- '■^ , iubo, ' '' Bulletin de la Faculte de Med. de Paris." 1819, t. vi. p 396 ' Loc. cit. p. 130. ^ ' Loc. cit. » Ziemssen's " Cyclopedia," vol. vi. p. 911, et scq. 52 DISEASES OF THE THROAT AKD NOSE. is eeneraUy limited to one tonsU. The symptoms wWcli usher ra'an attaJk of quinsy are those of ^ ^^^l^^ ^^:^''^. thirst and heat of skin and m he ^^^^H^Z^^oJ^r. a rigor, and occasionaUy vomitmg. T^^JJ^^f^tig^ess and accompanied or quickly ^^^cceeded ^y^^^'/ ^^^e con- dryness in the tl-oat which leads the 1^^^^^^ stant efforts at degMitiom J^Y ^g^^ f ^^^^ increases hecomes more painful, and as tne ioodi ^ ^^^^ the symptomatic ^^^^^ an extent not previously suffered from ^'^\^^Xmiev£Te ir. the first that in the case of young P.^^^.-^^^^^,^^^^^^^^ forty-eight hours may reach f^^^ J,, fo,^ of tonsil- phenomena are less marked -Xnmation is about to iitis, and -^^-^-^K'.^'^Z'^ J^^^^^ 1^°-^^^^' lead to the formation of an f^^^f't^h^^^^ runs high. who are subject to ^J^e ^^l^^^yj^fj^ C occasionally In those of debilitated f^^^^^^^, Ji^/r^ffec^^^ after a assumes a typhoid character, ^^dst tlie ioc ^^^^^^ few days subsides ^^o a subaci^e fo m^^^^^^ are partiaUy covered mth an ashy exudation 01 j U ragged f i^^htX lacuS: ofthe ^glands mena are most apt to occur wub , formations, are blocked up by caseoi^ matter or cto^ ^^^^^^^^^ In the ordinary run of f ^'""^.^.w to block up the tonsil becomes so ^^^^fl^^i^.fl^.t'Jhl whole phaiT^^^^^ isthmus of the throat and to fill almoBt cavity, rendering deglutition so ^xtreme^y^ ^,,triment even cult that t^e patient IS aftaid 0 sw^^^^^ ^^^^^^^ in the liquid form. In toi^fiiar to ^^enibrane is the tonsils is less ^^^^^f ^'^^i^' .^^f fo^^^ exude a wliite of a very bright colour an^^ foUic ^^^^ secretion, ' throat the idea that gives the patten who ^--^^^^us tonsiUitis, there xs he has several ulcers. In P^^^^^ncrease in size of the tonsils, not only g^^^V'^'^frts of Z Z^ynx and palate may but all the adjacent parts ^ne pn y ^^^^^^^ he seen to participate m he ^orbi^^^^^^^ ^^^^^^^ secretion and a viscid sahva dog the m^^^^^^ The sufferer, and respiration may be s ^^^^^^^ ^ voice acquires a nasal i^\°~'; opened, the head is moved whisper, the mouth c^J^/^^f ^ ^^^i^f of the deep tissues of with difficulty owing to the . f^^id. Under these the neck, and the ^^^'^.^.^^^ViS an^ ^om.ihnes impos- circumstances it ^^J^^^jX^ ons^^. In many cases- sible, to get a view of the innameu TONSILLITIS. 63 especially in the follicular form of the affection — after the disease has lasted two or three days the pharynx becomes covered with a layer of dirty, yellowish, mucus, which bears some general resemblance to the false membrane of diphtheria, and has sometimes led to an error in. diagnosis. The mucous secretion, however, Avhich covers the tonsils in quinsy, pos- sesses neither texture nor adherency, and can easily be wiped off the surface of the glands. Yelpeau ^ and Beraud have observed instances in which the inflammation extended through the ceUular tissue of the neck as far down as the clavicle; whilst Morgagni^ and MM. Eilliet and Barthez^ report cases in which tonsillitis terminated fatally by suffocation. In almost all severe attacks of quinsy the hearing is affected, and occasionally the extension of the disease up the Eustachian tube gives rise to inflammation of the middle ear.''^ CEdema of the glottis is also a complication of quinsy, but happily a rare one; the inflammation, however, more frequently extends to the epiglottis^ and the base of the tongue. _ Follicular tonsillitis usually undergoes spontaneous resolu- tion in three or four days, but in parenchymatous inflammation or abscess of the tonsil a healthy condition of the parts is not generally re-established for ten days or a fortnight, and the disease may even . be protracted for three or four weeks. Slight ulceration of the tonsils nearly always remains when the inflammation has caused the extrusion of inspissated cheesy matter or calcareous concretions which had previously blocked up the lacunas of the glands. Occasionally a number of small superficial abscesses or pustules form on the surface of the tonsils, and these abscesses on discharging themselves give rise to ulcerations which, in cachectic persons^ are very obstinate in healing. Gangrene is a very rare termi- nation in tonsillitis, but may happen as a consequence of the highest degree of parenchymatous inflammation. Cases have been seen by Grisolle,fl Trousseau,7 Frank,8 and especially by Borsieri,9 according to whom the phenomena of such an issue 1 "Manuel d'Anat. Chirurg." Paris, 1862. The authors demon- strate the continuity of the areolar tissue covering the tonsil- with the general areolar tissue of the neck. ^ "De sed. et Caus. Morb." epist. xliv. ! ll Traito des Mai. des Enfants." 1853, vol. i. p. 227 ^ FoUin : " Gazette Hebdomadaire." 1864, p. 155. » Louis: " Bulletin deTherap." 1843. 7 .\'^,T'^i.*eclePathoiogie Interne," t. i. Art. "AmygdaUte." 1862 I ::Climq"e M6d. del'Ho^^^ Paris, 1865, 2nded. t. i. p. 392: p n4 vol ii 164''^^'^ Pratique, trad, de Double." 1842, vol. i. " De Angina, " Institutiones de Med. Prat." 1798, t. iii. p. 343. 54 DISEASES OP THE THROAT AND NOSE. are a sudden diminution of pain and dysphagia, the appear- ance of a bluish patch on the tonsil, and after a day or two the expectoration of a nutrid, sanious matter, having a pecuhar odour, -which BorsieritHnks pathognomonic of the occurrence. I have never met with such a case. When tonsUhtis proceeds to suppuration, the patient usuaUy complains of lancinating pains in the part, and well-marked rigors generally precede the formation of an abscess. It is unusual for both tonsilfi to become the seat of an abscess, but when such an occur- rence does take place, suppuration very rarely occurs in both olands simultaneously. One gland becomes aifected alter the other has suppurated, and the inflammation may terminate m abscess. As a rule, the pus shows a tendency to evacuate itself at the anterior part of the tonsil, and the abscess pro- iects towards the mouth. Occasionally, however, it points near the posterior wall of the pharynx, and under extreme y rare conditions may make an opening for itself externaUy at the angle of the jaw. If the abscess be not opened by the surgeon and do not burst spontaneously, it may occasion so much sweUing internally as to interfere seriously with res- pu-ation. Professor Stoerki tas pointed out that fluctuation may often be detected at a very early period by placing the fingers of one hand beloF and behind the ramus of the lower jaw, and pressing the soft tissues inwards, ^J'^^il^t the index iincrer of the other hand is introduced into the mouth and placed in contact with the inflamed part ^^^^^ the pus has been known to burrow through tl^^/f ^^^^Jf^f^^ of the neck as low down as the upper surface of the clavicle. In a case reported by Montague,3 the quantity of ^f^^ ^^ so great that the patient, a young soldier, was suffocated by the sudden bursting of the abscess. At the post-morteni ttm^iation the larynx and the upper part of the trachea and SoXus were found filled with pus. Such an accident as tTe fSoiug is most to be dreaded should the abscess burst duriu' sleep! A curious case is recorded by Koche,^ m which Hus Tom a tonsillar abscess passed along the course of the ^eat vessels of the neck and penetrated into the chc ; Abscess of the tonsil is also dangerous on account nal face of the gland being m close proximity to the mtemai 1 -KhBik der Krankheiten des Kehlkopfs." Enke, Stuttgart, 1876, p. 109. 3 IdK. de°ln'^aTon.mari," Sec Str-Wg 1823. 4 u Diet! de Med. %t de Chh-urg." Ai-t. " Amygdahte. 1829. TONSILLITIS. 55 «caroticI artery. After middle life, according to Chassaignac,i ihe artery in this situation describes a curve with the con- vexity directed inwards, which brings it still closer to the .tonsil. Grisolle ^ mentions a case in which the abscess gave rise to ulceration of this vessel, and thus to serious hasmor- i-hage ; whilst Caytan,-'^ Muller,''^ i^orton,^ and others report ■simiiar instances which led to an immediately fatal result. Chronic enlargement often remains after the aciite inflamma- tion of the glands has passed away. Paralysis of the pharynx and palate, with or without anesthesia, somewhat similar to that which so often follows diphtheria, is also an occasional consequence of a severe attack of quinsy. ^ It is a rare condition, and when present is generally limited to the side of the throat which has been the seat of the tonsillitis. Paralysis of the pharynx is indi- cated by a difficulty in articulating those soimds wliich require the closure of the posterior nares, and by slight dysphagia, which is found to persist long after all the acute symptoms of the malady have subsided. The difficulty exists in making the first effort of deglutition, and can usually be overcome by .a Little resolution on the part of the patient. As soon as the bolus passes below the superior constrictor, it proceeds •downwards to the stomach without any further difficulty. When the soft palate is alone affected, and the rest of the pharynx escapes, the symptoms are less marked. There may be, however, slight difficulty in swallowing — especially fluids, and nasal intonation of the voice. These palsies are, Jiowever, such rare sequelte of quinsy that it is scarcely necessary to refer to them except as possible results. Patliology. — As tonsillitis so rarely proves fatal, few opportunities have occurred where the pathologist could •demonstrate the precise effects of acute inflammation on these glands. When the morbid action is superficial the mucous membrane, which covers the tonsils and dips into the lacimte, is ahnost the only structure affected. In cases of ' "Legons siu- rHypertrophie des Amygdales." Paris, 1854, p. 7. - " Traite de Pathol. Interne." Paris, 1862, t. i. p. 269. 3 " Prager Vierteljahrsschrift." 1861. " Wurtemberger Med. Corresp. Blatt." 1855. ^ " The Throat and Larynx." London, 1875, p. 12. Mr. Norton's patient was a little girl set. four. ° See cases by Maingaiilt : " Snr la Paralysie du Voile du Palais a la Suite d'Angine," Paris, 1853; Gubler: "Memoires sur les Paralv- Me8,"&c. ; " Archiy. de Med." 1860-61. 56 DISEASES OP THE THROAT AND NOSE. parencliymatous inflammation, however, a much more import- ant series of phenomena may bo observed. Thus, in an instance recorded by Didelot,i the autopsy revealed extensive suppuration in the substance of the right tonsil, whdst the uvula was cedematous, and the mucous membrane of the palate infiltrated wiih pus. In addition, the base of the tongue was thickened and engorged, the follicles being filled with a concrete sebaceous matter, and a section of the organ showing effusion of pus between the muscles. In the- case of Montague already referred to, inflammation and thickening of the walls of the internal jugular vem and its branches were found at the post-mortem exammation. Pus and clots were also present in the interior of these vessels, which accounted for the engorgement observed in the sub-max- iUary and parotid glands and the neighbouring lyuiphatics. The tonsUs often remain persistently enlarged alter an attack of tonsiUitis— the result of thickening and induration of the parenchyma of the gland. _ Diagnosis.— The diagnosis of tonsiUitis presents httle difli- cidty Nevertheless mistakes are frequently made, and the hi"h mortality attributed to tliis disease in the aimuai returns of the Eegistrar-General, to be hereafter referi-ed to, must be due to this cause. I have twice been consulted^ m cases of tonsiUitis mistaken for laryngitis. In both affec- tions there may be pain in swaUowing, but when the larynx is the seat of inflammation the voice almost always becomes hoarse or is reduced to a mere whisper at an early period ot the attack. In the laryngeal disease inspection ot the pharynx at once shows the absence of any lesion in the upper mrt of the throat, whdst the laryngoscope reveals the actual condition of the larynx. Some discrimination is reqmred m order to distinguish the sore throat of the first stage of scarlet fever from tonsilUtis. Even hydrophobia has been mistaken at its outset for quinsy. The whitish foUicular secretion which often veds the tonsils in tonsiUitis has caused the Xction to be mistaken for diphtheria, and has led to the supposition that the more serious disease had been cui-ed by some simple measures. In aU cases it is weU to suspend the uSLeTfor twenty-four hours, after which time the dive^^ ienS^ of symptoms in any of the maladies which smiulate qSnsy is so apparent that the careful observer can usuaUy arrive at a positive decision. Prog7iosis.-The prognosis as regards life is so seldom 1 I'AmygdaUte Aigtxe"-"Tli&sede Paris," 1850, No. 153. TONSILLITIS. 57 imfavoiiralDle that the rare cases -ffluch terminate fatally must be viewed as merely accidental.^ It is well, however, to bear in mind the possibility of such casualties in order to foresee and obviate them when the symptoms announce the advent of grave complications. With respect to complete recovery the prognosis in tonsillitis is not always favourable, though it usually is so in patients of sound constitution. In debilitated persons there is great probabihty of hypertrophy and chronic inflammation of the tonsils remaining after a severe quinsy. A hability to frequent subsequent attacks is also one of the most troublesome after-consequences of this disease. Treatment. — The superficial forms of tonsillitis generally undergo spontaneous resolution in two to five days, and call for little treatment beyond such simple measiu'es as confine- ment to the house, a light diet, and a dose or two of some mild aperient. A rhatauy lozenge (Th. Hosp. Ph.) taken every three or four hours will also materially hasten the cure of the disease. In cases of deep tonsillitis the treatment required is much more active, but fortunately there is a remedy which if administered at the outset of the attack will almost always cut short the crescent inflammation. This is guaiacum. Dr. Home,2 who well remarked, instar sp)ecifici in Jioc morbo operatur, did not at all overstate the influence of the drug. It was formerly much given for this complaint in the form of the ammoniated tincture, but fifteen years ago Dr. Crompton, of Manchester, recommended me to try it as a powder. Taken in this way it seems to have a local as well as consti- tutional effect. Soon after I prescribed it as a lozenge, and it is now largely used in that form. A lozenge contain- ing three grains of the resin (Th. Hosp. Ph.) given every two hours will seldom fail to arrest the disease at its first onset. Tincture of aconite in doses of two to five minims every three houis is sometimes very efiicacious. This remedy, for which 1 According to the Registrar-General's Eetiims, 226 persons died of quinsy in England in 1875, and the number has varied between 110 and 569 every year since 1848, except in the year 1858, when 623 deaths were returned. It is well to bear in mind that in that year diphtheria attained great epidemic force, whilst it was still but little understood and sometimes altogether imrecognized. The mortality returns gradually decreased from that time, and feU as low as 110 iu 1872. It is scarcely necessaiy to point out that these returns are the results of errors in diagnosis, and it is a matter of regi-et to find that lately there has been a slight increase ia the retm-ns. Thus in 1873 the reported deaths were 158 ; in 1874, 173 ; and in 1875, 226 ! - " Pnucipia Mediciua3," part iii. sec. 4. 58 DISEASES OF THE THROAT AND NOSE. -ive are in a great measure indebted to homeopathy, has been strongly recommended by Dr. Kinger,i -yyho advises that half a drop or a drop of the tincture, in a teaspoonful of water, should be given every ten minutes or quarter of an hour for two hours— and afterwards hourly. According to Dr. Einger, a high temperature both affords the indication for the administration, and assures the success, of this remedy. In my hands this drug, however, has not proved so useful as guaiacum. When the disease is _ not seen at the commencement, the above remedies will fail to shorten its course, but the constant sucking of ice may still sometimes prevent the further development of the attack. We must also have recourse to such general therapeutic measures as are calculated to guide the morbid action to a favoui-able issue. The bowels should be kept open, the diet should consist entirely of nutritious soups, milk, &c., whUst locaUy, mildly astruigent or sedative gargles, of tannin, borax, opium, &c., may sometunes be used with advantage. The immediate sensations of the patient are the best guide as to the use ot different kinds of gargles, or, indeed, as to the employment of gargles at aU. Sometimes they cause great pam, and should not then be used. A dose of Dover's powder at.bed- time is also very beneficial when there is much fever and vascular excitement. Some practitioners have confidence in the direct application of mineral astringents, and Yelpeau - •especiaUy recommends powdered alum and nitrate of silver. The pigment of cUoride of zinc (Th. Hosp. Ph.) brushed over the inflamed tonsUs two or three times a day is some- times productive of great benefit, and even less frequent applications often do good. I quite agree mth Trousseau, however, that there are certam cases in which the in- flammation inevitably leads to suppiuation, and that m these cases aU remedies are powerless to turn it Irom its path The morbid action marches onwards, uncliecked in its course, until the formation and discharge of pus announces the completion of the process. In these cases of tonsillitis with ahscess the best endeavours of the medi- •cal attendant should be directed to encouraging si^pu- ration and shortening the stages of the disease. ^^ ith i)his view a constant succession of warm poultices should be kept applied to the throat, whilst the patient shoiild make pSseverLg use of hot inhalations of steam to which some 1 " A Handbook of Therapeutics." London, 1872, p. 385. 2 Op. cit. t. 1. p. 463. TONSILLITIS. 59 sedative, such as benzoin, hop, or conium (Th. Hosp. Ph.) may he added, and he should also gargle frequently with warm water. As soon as pus has formed, it is hetter to open the abscess at once than to leave it to evacuate itself spontaneously. The incision should be made with the pharyngeal bistoury, the point and cutting edge of the Icnife being directed upwards and inwards towards the median line. In the case of very nervous persons who are afraid of the Icnife, the immediate rupture of the abscess may often be attained by the ad- ministration of an emetic. Once the matter is evacuated, relief is generally almost instantaneous, though convalescence may occasionally be retarded in those of feeble organization. On this accoimt it is always important to sustain the con- stitutional powers as far as possible. Formerly the abstraction of blood, either general or local, Avas the primary treatment in all cases. The researches of Louis,! however, proved how little benefit may be expected from general bleeding. Thus, out of twenty-three patients suf- fering from parenchymatous tonsillitis noted by that observer, thirteen underwent venesection and ten were treated by other methods. The duration of the disease in the former cases was, on an average, nine days, whilst in the latter it was ten and a quarter days. Tliis shght abridgment of the course of the malady cannot therefore be considered to compensate for such energetic interference. With respect to local bleeding it has been recommended to apply leeches at the angle of the jaw or to scarify the tonsils with the pharyngeal bistoury. If only one or two leeches are applied to each side, the effect appears to be the opposite to that desired, and an increased congestion of the tonsils often results. The good effect of the local abstraction of blood can only be obtained by the application of from three to six leeches on either side. A special kind of local blood-letting, i.e., opening of the ranine veins, has within the last twenty years been practised to a considerable extent, and much vaunted in certain parts of France. The principal advocates of this measure, which is as old as Hippocrates, are MM. Arago^ and Aran." The latter writer insists on the incision being made longitudinally in the veins in order to avoid wounding the ranine arteries, an accident which, on account of the serious haemorrhage it J " Lancette Fraii9aise," 1833. Tt,--.",',^-^'^^'^*"^ General de Therapie," &c., 1853. Also Mestivier, ibicl. 18o7. ' Ibid. 1857. 60 DISEASES OP THE THROAT AND NOSE. entaUs, would be Hkely to briug this kind of bleeding into disrepute. Although I have never seen any cases m wJiicli such heroic remedies were caUed for, the proceeding certainly appears to have been attended with remarkable success m tli& hands of Aran. i 4-^ In cases wbere the swelling of the tonsds is so great as to threaten suffocation, and where it cannot be dinunished by the escape of pus, we must follow the example of Ancelon, and at once excise the inflamed masses. In the middle ages tracheotomy was suggested in such a juncture, but the opera- tion was not actuaUy performed under these circumstances until the last century. In a recent mslance, related by Puech,2 of a man, ^t. 33, who was evidently dying from asphyxia, and on whom the attenipt to ^^^^^^^^^^^^^^ faUed. recourse was had to tracheotomy with the result of saving the life of the patient. Tracheotomy was also per- formed by Mr. Alexander Shaw » under similar circumstances. Should tonsiUitis terminate in gangrene, treatment by antiseptic gargles will be sufficient untd the sphacelated portions of the tonsil become detached, when the raw surfaces remaining wiU usually heal rapidly under apphcations of nitrate of silver. EKLAEGED TONSILS. Lntin iJf?.— TonsiUse intumescentes. French JJg.— Hypertrophie des amygdales. German ^g.— Hypertrophic der Tonsillen. Italian J^g.— TonsiUe ipertrofiche. DBPiNiTioN.-aromc injiamnatlon of the tons f,/^^^ rise to persistent enlargement and midtipliccdion of the con- stUuent structures of the diseased part, and to wipamnent of the functions of the glands. xj^.^^oav -Hypertrophy of the tonsUs is sometimes con- ea£° monto of Utence. The toease not nnf.o- 1 <' Gazette des H6pitaiix." 1857._ 2 " Gazette He-bdomadaire." 18o ( , p. 5J/. 3 " Medical Gazette." 1841, p. 190. ENLARGED TONSILS. 61 quently becomes developed for the first time about the age of puberty, owing, as some suppose, to a sympathetic connec- tion between the sexual organs and the tonsils.^ The follo-sving table^ contains an analysis of the ages of 1,000 patients seen by me at the Hospital for Diseases of the Throat :— 1 to 5 . . . . 84 5 to 10 .. ..181 1 Under 10 years . . 265 Prom 10 to 20 >> • • .. 382 20 to 30 >) .. 219 30 to 40 ») .. 103 40 to 60 )> • • .. 27 60 to 60 )) • • .. 3 60 to 70 J) • • 1 Probably many of the cases in the earliest period were either congenital or made their appearance very soon after birth. Sex is not without some influence in producing the affec- tion, for out of the 1,000 instances recorded in the preceding table, 673 were males and 327 females. Some cases of hypertrophy of the tonsUs result from an attack of quinsy, but a cachectic state of the constitution, especially if due to the strumous diathesis, more often originates the disease. The morbid condition of the glands may frequently be ob- served to date from a severe attack of scarlatina, measles, or smaU-pox with throat complications ; and Lambron ^ mentions four instances in which the malady was consequent on an attack of diphtheria. Syphilis, hereditary or acquired, is iilso capable of producing chronic inflammation of the tonsils, and grantdar phaxynx * is, in some instances, the immediate cause of the malady. Chassaignac ^ mentions a case of nasal polypus which appeared to have had some efl'ect in giving rise to tonsillar enlargement. As a rule, hypertrophy of the tonsils, by whatever influence established, tends towards a •spontaneous cure after the age of thirty, and subsequently to that period of life the vokime of the glands diminishes so steaddy and constantly that the decade of from forty to fifty affords few instances of the disease. ' Crisp and Headland: "Dublin Medical Press," 1849, vol xx p. 229 ; and Prosser James : " Med. Times and Gaz." Sept. 1869. 2 See also Chassaignac : " Lecons sur I'HjTpertropliie des Amvs-- dales." Paris, 1854. "^^ " "Bulletin de I'Acad. de Med." 1861. ■* Gueneau de Mussy : Op. cit. 5 Op. cit. p. 11. 62 DISEASES OP THE THROAT AND NOSE. Sipnjytoms.—We can often predicate the existence _ of enlarged tonsils as the child, with its open mouth, drooping- eyelids, duU expression, and thick voice, enters the con- sulting room. On looking into the pharynx we can generaUy at once perceive the hypertrophied tonsils, and in some cases they are seen meeting each other in the middle Ime of the pharynx, and entirely concealing from view its posterior wall. The auomentation of volume of the tonsils varies m different cases. °They are often the size of a chestnut, hut sometimes attain the dimensions of a hantam's egg, and in rare instances they are nearly as large as hens' eggs. The disease generaUy affects hoth tonsils, hut one gland is nearly always more enlarged than the other. -u i. Sometimes the tonsils are only slightly enlarged, hut the iat^ged surface and dUated lacuna3 present a honey- comhecf appearance, and render them very prone to m- flammation. . „ ,■, -i Any considerahle degree of enlargement of the tonsils gives rise to some difdculty in respiration, and there is generaUy noisy breathing— often snoring— drawing sleep. As the pos- terior nares and naso-pharyngeal cavity are more or less cut off from the lower part of the pharynx by the enlarged glands, resphation through the nose cannot he carried on with sufficient freedom, and the patient is consequently ohhged to keep his mouth constantly open. In swallowing, he sometimes experiences the sensation of a foreign body m the thi-oat, and occasionaUy there is a difficulty m opening the mouth, owing to the enlarged tonsUs interfering with the movements of the angle of the jaw. In infants, enlarged tonsils often interfere with sucking. , , . , Attention has already been caHed to the facial expression of children afflicted with enlarged tonsils, but it may be remarked that the peculiarities of physiognomy are the results of the profound impress which the disease exercis s on the whole system. The phenomena are mamly due to the mechanical effects of the enlarged glands m obstructing SspSn. The simplest and most common of the mechamcal eZts of enlarged tonsUs is, however, thealteration which he voice undergoes. The cavities of the pharynx and nose, which form i it were the sounding-board for the vibrations set in motimi by the vocal cords, have their functions m this S pect more or less destroyed, the voice part^- of ^ nya intonation, and the speech becomes thick ^ndj f t'^ral. The defect in Lrticulation is especially noticeable m the case ot ENLARGED TONSILS. 6a cliilcli'en between the ages of six and twelve in whom the hyjDertrophy is excessive. Interference with the sense of hearing — in some cases amounting to ahuost complete deafness — is a freqnent con- comitant of hypertrophy of the tonsils. It was at one time supposed that compression of the orifice of the Eustachian tube played the principal part in the production of "throat deafness," 1 but the observations of the late Mr. Harvey- tend to prove that the increase in the size of the tonsil proceeds in the direction of the mouth, and that as the tonsil enlarges the Eustachian aperture becomes more patent than in the normal state. He therefore attributed this form of cophosis to chronic sweUing and congestion of the mucous- membrane of the Eustachian tube, and recent^ researches have shown that one of its chief causes is pressure of Luschka's tonsil on the posterior lip of the Eustachian orifice. Of all the evil results attendant on hypertrophy of the tonsils, those due to interference of the diseased masses with free respiration are the most serious. The partial occlusion of the nasal channel posteriorly by the enlarged tonsils, obliging the patient to keep the mouth ahnost constantly open, renders him unusually exposed to all the external influences which produce inflammatory affections of the respi- ratory tract, whilst the persistent obstruction to respiration leads to serious changes in the thoracic parietes. In 1828, Dupuytren* called attention to the frequency with which deformity of the waUs of the chest was found associated with hypertrophy of the tonsils, without, however, signalling anything besides a mere coincidence between the two phenomena. He described the modifications in the shape of the thorax as consisting in narrowing of the anterior super- ficies, bulging out of the back, and flattening on both sides, but these changes are more characteristic of rhachitic disease. Subsequently, this subject was stni further investigated by several observers, but principally* by Mason Warren,'^ Shaw,» 1 Chassaignac : Op. cit. p. 37, et seq. , l,'"^^^ "1 Health and Disease," London, 1865, p. 162; and "The Enlarged TonsU," &c., London, 1850, p. 21, et seq. 3 Michel: " Krankheiten der Nasenhijhle," &c. Berlin, 1876 p. 102, et seq. ' * " Eepert. d'Anat. et de Physiol." 1828, t. v. ^ "Philadelphia Medical Examiner," May, 1838. « "Medical Gazette," October 29, 1841, p. 187, et seq. 64 DISEASES OF THE THROAT AND NOSE. Eol^evt,^ and LanW Mr. S";™:^^^^^^^^^^^ ^^^r^^ — d^e the credit oi" - pigeon-breast, ^ ^ Jpd the various morbid cliang^^s, and having most ^ , le^f ^^^^^^^^ - tborougUy rational of having explained ^^^^l^^™ characteristic malfor- manner. According to -^f^"^^^^'^' ^ • ^^g^g of enlarged nation of the thoracic cavity met ^^^h m f ses ^^^^o tonsils is a_ circular clepression th w^^s^^^ ^^^^^ about the junction of the lo - ,,,yi,Ming thorax seems as if it f a*;^ ^^^i, this situation, Xing which, while -'f^^^l^^^^:^^^ to the upper part gi.es an a—c e t^'^^on corresponds with the of the cavity. iHis circuid i ^ ^ ^^le osseous frame- attachment of the chaphragm 1^^^^^^ work of the chest, ^^^^f^^^/to overcome the obstacle getic contractions of tha^ -^c^^ ^3,,,, yield easUy to to free respiration In ^^"^"^^^^ witnessed the difficulty such influences, and any one who 11^^^^ ^^^^^ of breathing which ' ^^^f^^^^^^^ of the tonsils, will there is any its effects on the xeadily understand howgr«^^^ ^^^^^^^ respiratory apparatus are brought about, in the bones of ^^^f^^^es that although increased and Chassaignac^ well oOseive neutralize efforts of the diaphragm to a certai .^^^^^^^^ the impediment ^o -P-^^^^^^^^ when the powers of the musae o ^^^^ incompletely ^^r^ ^ces a. — ^t^^, the -P;;^^^^^^^^^^^^^^ on h,Ter- Besides the ^^'"'^J^^'^ZT Gh^^^^^^^^^ ^^^^^^^^ trophied tonsils, as ^^^a^^^,^^^^^^^ of^the disease on several cases to ill^^^ J^^f on the senses of sight, the brain, t^e digesUv Jg- >^an ^^^^^ of he taste, and smeU. ^e thnilcs tn enlarged glands /^^.^^^^^^^^^^^ the digestive organs brain, and i^P^^^^/|-ffieX of swallowing, and also when rdireStnsi;: putnd matters which And ... Bulletin a6n6ral^TK.H^;^-^^'"*°iS- 2 T.r,^> fit. ^ ENLARGED TONSILS. 65 tlieir way into tlie stomacli. Witli respect to smell and taste, I have often observed that these senses are more or less defective in the subjects of enlarged tonsils, if the con- dition has existed for any length of time. As regards sight, however, I have not met with any cases in which I coidd trace any clear connection between affections of the eye or modifications of vision and enlarged tonsils. Pathology. — The diseased condition is a true hyj^ertrophj^, a veritable hyperplasia, in which the volume of the glands is not only increased, but increased by a multiplication of Fig. 9.— Section of the Heaithy Tonsil. A.Hilus; B, Mucous gland ; c, Epithelial covering ; d, Lymphatic folUeles • E, Stroma. ' all their constituent tissues and foUicles.i Accordino- to Chassaignac ~ the limit of weight of the enucleated tonsil in the cases which he examined was from three grammes two centigranunes to seven grammes fifty centigrammes. The epithelium does not usually show much alteration, but the papillas beneath are often more numerous and less elevated than m the normal state. On making a section of an en- larged tonsd, in some instances the structures will be found to cut with a creakmg noise, owing to thickening and indu- ration of the connective tissue, whilst at other times the substance of the diseased gland is found to be characterized by softness and friabihty. The colour of the cut surface ' Virchow: " Ki-ankhaften Geschwiilste," vol. ii. r, G12 ^ Op. cit. p. 13. ^ P DISEASES OF THE THROAT AND NOSE. may vary from a dusky-red to a dirty-yellow hue Tiie lacunae Z'seen to be dilated, and to have their ^h-kened ^vloUst their cavities are filled with a vxscid J^^^^ some cases becomes consolidated mto -^f^^^^J'^'^^^^l even calcareous consistence. Around the lacun^ are con ..recrated the follicles of the tonsd, winch are ah^ays Fig. 10 —Section of the Bnlabged Tonsil. to suppuration and rupture of ^ome subjacent lymp development of Chassaignac : Op. cit. p, I ENLAKGED TONSILS. 67 lymiihatic glands of the jaw are in many cases considerably enlarged. 1 Diaff7iosis. — But little need be said on this point. It is only necessary to examine the pharynx in order to perceive the increased size, and often the diseased sm-face, of the tonsils. In some cases the tonsils, though actually but ■slightly increased in dimension, seem to have undergone great enlargement, owing to their being rotated forwards and inwards towards the median line.- In this way they present then- internal surfaces anteriorly and, stretching across the front of the pharynx, closely approach each other. In some persons this movement, which is semi-involuntary, occurs to a much greater degree than in others, and in such cases the pecuharity is at once seen 'if a disposition to retching is artificially produced. If, however, the patient be told to open his mouth and inspire deeplj^, the normal position of the parts wiU be generally retained. At other times the tonsils, although much hypertrophied, are yet ahnost hidden behind the pillars of the fauces.^ This con- dition can easily be diagnosed by placing the first finger of one hand on the internal surface of the tonsH, and that of the other hand externaUy just behind the angle of the jaw, when an accurate estimate of the proportions of the gland can at once be arrived at. A little familiarity with the usual con- formation of the pharynx wiU prevent either of these appearances leading the observer into error. It may be remarked that retro-pharyngeal abscess has sometimes been imstaken for enlargement of the tonsils. Pro^/raosk— Hypertrophy of the tonsUs occasionally exists m the adult— and even in children— without giving rise to any inconvenience or evH effects. Such cases are, how- ever, quite exceptional, and in early life especiaUy the disease is one wliich ahnost always requires immediate attention. The enlarged tonsUs sometimes spontaneously regam their normal dimensions about the age of puberty Out by that time the morbid condition may have seriouslv impaired the general health of the patient. When the hypertrophy takes place in adult life, it is seldom pro- ductive of any evil consequences, except in so far as it occasions local inconvenience. Should the bodily powers however, be feeble, the constitution is likely to suffer, and in I Griesinger: "Ai-cHv. f. Phys. Heillamde," vol. iv. p. 515 - Chassaigiicac : Op. cit. p. 8. ^ • Ouersant: " Hypei-trophie des Amygdales." Paris 186'' 68^ DISEASES OF THE THROAT AND NOSE. any case the disease becomes important Avhen, as is often the casl the gland is frequently attacked by slight -AammaUon It is well, however, to remember that after the age of thirty a progressive diminution in the size of the tonsils and a giilual cessation of all the troublesome symptoms, are almost ^^^^!:;S:;ariousmeasures ^^^ff^f^^^tl of the tonsils may be conveniently divided into loud, con- stitutional, and operative. v.nf^.,. nf rmnedies to Local ireatment consists m ^lie application of re^^^^^^^ the tonsils in order to effect a dmunution of then volume. Whence nlargement is slight, and in a gi^eat measure due- to i™-ular thickening of the mucous membrane covering the ton £°td to^^^^^^^^ of the lacuna, producmg the l^oney^ comt/appearance already described, astringent prepare ^^^^ Tofteniroductive of decided benefit ; but such agents nevei :iLeX' onsiderable reduction of the gland Btx-ctuiu Tlie S St effective astringents in such cases a- perch^^^^^^^^^ of iron in solution, and alum or tannin in V^J^^^- ^ solution of percliloride of hon (3j to 3iJ ^^V^^i a pSed over the tonsUs once or even tmce f ^^J ""^^^^ brSh Finely powdered alum or tannin can be effectuaU, app fed M means of the pharyngeal spatula _ The extreimtj rthe spLla shoiddbe ^^^'^^^ ms Varanswers better than applying the powder with necessity for excision of diseased tonais. its appUcation has already been described {V^^^^^^' to I'ion maybe repeated once or --^/J^J^-^X to^il. circumstances, on differen part of the sui ace o ^^^^^^^^ On each occasion the result is a f f ' J^^^^^jf f,, gucces- of the diseased mass may thus be destiojea ENLARGED TONSILS. 69 sive layers, until the glands have heen i-educed to a normal volume, or at least to such a size as to cease to give rise to troublesome symptoms. It must be confessed, however, that tlie treatment is tedious, and that the guillotine affords a quicker method of effecting a complete cure. I have treated a few cases successfully by parenchymatous injections of dilute acetic acid (B.P.) with a curved syringe, but the treatiuent is slightly painful. From ten to fifteeii injections Avere used in each case. Dr. Solis Cohen ^ has reduced the enlarged glands by electrolysis — from ten to twenty operations having been required in each case. Constitutional Treatment. — Whilst any of the measures detailed above are being carried out, internal remedies should be administered in order to improve the general health, or to combat the morbid diathesis which may be present. With this view the diet should be as nutritious as possible, and the patient sliould be treated with special drugs or general tonics, such as iodide of potassium, cod-liver oil, and phosphate of iron, &c., according to the circumstances of the case. Lambron- speaks highly of the effects of sulphurous waters (Bag]ieres-de-Luchon). The patient drinks and bathes in the waters, has them applied directly to the ])harynx and neck by means of a douche used daily for five to fifteen minutes, and employs spray inhalations. Dr. Lambron states that the general health is always much improved by a course of these mineral waters, whilst in very many cases the tonsillar liypertrophy undergoes resolution, and the glands are almost reduced to their normal size. Operative treatment consists in the removal of a portioai^f tlie tonsils by abscission. 1 " Diseases of the Throat." New York, 1872, p. 132. - Op. cit. Extirpation of the Tonsils. — This operation must have heen com- monly practised at a very early period, for although the first clear mention of it is made by Celsus'— a.d. 10— he speaks of excising the tousUs with such familiarity that it was evidently considered a very ordinaiy and tiifling procedure. He observes :—" Tonsils which remain indurated after inflammation, if covered by a thin membrane, . shoidd be loosened by working the finger roimd them, and then torn out ; but when this is not practicable they shovdd be seized by a hook and excised with a scalpel." ./Etius a.d. 490— the next miter who gives an accoimt of the operation, speaks of it in much more I'autiouH tei-ms. " The portion," he remarks, " which projects -j.t., ' "Be Mod'cinn," pnti. vii. sect. 12. " Bi^Afa 'larpiica 'E/<)caI5e/ca." Venice, 1531, cap. ii. sect. .30. / 70 DISEASES OF THE THROAT AND NQSE. about ouc-half of the enlarged glaud— may be removed. Those who extkpate the entire tonsil remove at the same time structm'es which are perfectly healthy, and m this way give nse to serious heemor- rhaoi" Paulus ^gineta i-a.d. 750-instructs us as to excision ot the tonsUs very precisely. He does not approve of operating on them when inflamed, and describes them as bemg most fit for removdl when they are " white, contracted, and have a narrow base. ihe head of the patient is held, and his tongue pressed do^vn Asath a spatula by assistants, and, the tonsil being seized and _dl•a^^^l outwaids by a tenaculiun, is " cut out by the root." Albucasis — a.d. 1120-- e^dently takes Pavil of ^gina for his preceptor, and gives ataiost the same directions for perfoi-ming the operation. He is, however, mo e cautious in his adAce, di-eads heemoiThage, and fears to excise the tonsils ^mless whenthe; are " roand, whitish, -^^'^f^^ZTIer^to Subsequently to this period the operation appears to have faUen into S^eTnd having become abnost obsolete and traditionaiy, succeed- So m-iter either'omit aU mention of it, or approach the subject with ^ch Wdity as to show that they had had no personal expenence. Thus even the zealous and indefatigable Ambroise Pare ^1009- cou^sels tracheotomy when serious enlargement of the tonsils exists anT^vesahintalsoas to ligatui-ing the hypeitroplued glands, bu make^no remark as to theii- excision. Fabricius, ^W-lente^ _1540-makes some comments on the i^^tmctions of Celsiis and Paul of ^gina, and comes to the following puerile conclusion :- Whence we can perceive that this sm-gical procedtu-e is neither easy nor alto- Sh r a. Wishing that^ll Aolence operation, we should, therefore, advise a tnal to be fi^';* loosen the tonsil from the sm-rounding structui-es with a ^;ecti« and then having laid hold of it with a veiy slender ^^f 1^^^'*° P^J^ outwards inVder that the gland may come away ^^ost of its o^ acS'' Guillemeau," the pupU of Ambroise Pare, advocates a bolder sm-ScaltreXent of the tonsils than did his master, and does not S to ti^he'otomy unless the patient's mouth cannot be n^d^ Accordin-to circumstances, he hgatured or cut away the diseasea massefand he is opposed to the removal of the entu-e tonsil. In 103 < Cerhli^ dSo- an epidemic at Naples, the pimcipal symptom of Sch^onSin greal swelling of the ^ons^^l-^^lX'^^^.^^^' tlnn^ of the o-lands, when sessUe, by caustics, and, wlien pemcuiareu, 1 New Sydenham Society's " Ti-anslations," vol. ii. p. 297. 2 "jU-Tasriff." Oxford, 1778, cap. u. sect 36. . . ogg •. " ffiuv?e"compl6tes," Edit. Maagaigne, Pai^s, 1840, 1. 1. p. 3S3. rsii&^»Mtd:^-^^^^ ENLAEGED T0N8ILS. 71 pupil of Cheselden — all fear to excise the tonsils, and condemn the operation, contenting themselves with feeble attempts to remove por- tions of the glands by ligatm-e or caiitery. The opinion of Heister is worth quoting, as his siu'gical treatise was, perhaps, the most popular text-book diu-ing the first half of the last ceutiuy . ' ' This operation, ' ' he observes, " is not only too severe and cruel, but also too difficult in the pei-fonnance, to come into the practice of the modems, because of the obscm-e situation of the tonsils. After 1740, however, the opera- tion by means of the tenaculimi and bistouiy was again much prac- tised, and the credit of the revival is piiacipaUy due to Meseati ' and "Wiseman.- The practice of the latter sui'geon was fii-st to ligature the tonsU, and then to cut o£E the projecting portion. In 1757 Caque ^ commenced to excise the tonsUs at the Hotel-Dieii of Rheims, and proved indisputably that the great di-ead which existed of hsemorrhage was quite chimerical, and that the resulting wound readily healed in a short time. From this date excision of the tonsUs became one of the recognized operations of surgery, and practitioners began to improve the instruments, and invent new methods for per- forming it. It is imnecessaiy to describe here aU the various hooks, forceps, bistoru-ies, &c., which were devised during the last century for the excision of the tonsils, as almost every eminent surgeon made some modification of the instruments used for the purpose by his pre- decessors or contemporaries. The method most generally in favour was, perhaps, that of Louis, ^ who employed a blunt-pointed bistoury or pair of scissors, the blade or blades being sometimes prefei-red curved and sometimes straight. The patient was placed with his face towards the light, and directed to open liis mouth widely ; an as- sistant then pressed down the tongiie with his finger, or with a spatula, whilst the siu-geon seized the tonsil with a vulsellum, and, drawing it as much as possible towards the median Kne, cut off the superfluous portion on a level with the piUars of the fauces. After a time the scissors gave way to the bistoury, and many surgeons still operate with the knife and forceps. A description of tlie tonsillotome or guillotine, and tlie mode of using it, will be found under "Pharyngeal Instru- ments " (p. 10). As regards the respective merits of operation by the tonsillotome, or by the bistoiuy and forceps, it is obvious that the former instrument ought to be used in all but exceptional cases. When the tonsils are only sUghtly and ii-regularly enlarged, or have calculi impacted in their sub- stance, the bistoury and forceps may perhaps be more manageable ; but in aU ordinary cases the tonsillotome must be considered to be the instrument which modern surgical invention has succeeded in perfecting for its purpose. In adults the tonsils occasionally attain such a magnitude ' "M^m. de I'Acad. de Chir." t. v. "Sui- la rescission des amvsdales ■, l'.^'^'** Chirui'gical Treatises." London, 1734, vol. ii. p. 30, Gth edition Amygdalotomie," 1757. AiiiygSs."^ *• P-^'^^' "Sur la rescission des 72 DISEASES OF THE THROAT AND NOSE. that they cannot be encircled by the ring of the largest ton- siUotome. This extreme hypertrophy generally takes place on one side only, and in such cases the wire ecrcmur should be employed. This operation, of course, occupies more tune than when the tonsillotome is used, but is attended with little pain, and does not cause any htemorrhage. „ Some practitioners are in the habit of giving large doses ot bromide of potassium for several days before excising the tonsils. I have made an extensive trial of this drug, but cannot state from my own experience that I ever saw it produce any marked anaesthesia of the fauces. In nervou.s patients, however, especiaUy chUdren, the general action ot the remedy, as a nervine sedative, may, perhaps, lessen the mental apprehension and nervous shock consequent on a surgical operation. With respect to the use of anajsthetics, such as chloroform, ether, nitrous oxide gas, &c., i thmJi that they are wholly uncalled for. The actual operation seldom occupies more than ten or fifteen seconds, and in tlie rare event of there being any considerable haemorrhage it is • AveU that the surgeon should have the active co-operation of the patient, in order to prevent the blood descending into the ak-passages. . . n .^ i. •!„ As regards hemorrhage foUowing excision of the tonsils I have only once met .vith a case in which the bleedmg appeared actually to endanger life-and this was before I had discovered the means of arresting tonsillar haemorrhage, which will be presently described. The experience of nearly all writers points to the rarity of any serious haemorrhage butVelpeaui has reported four cases ^^'^^^^ ^^J'^ ^^^^^^^^^^ carotid artery was laid open whilst a portion of the tonsil was being ciit away with a bistoury, and a few years ago Mr. McCarthy successfuUy tied the common carotid artery at the London Hospital in the case of a patient siiffering from continuous haemorrhage after excision of a tonsil, in thp oTPat maiority of cases the bleeding soon ceases spon- taneouSv and t is only necessary to make the patient 'X and wash the throat with cold water for a few Sis OccasionaUy a persistent oo-g ^^^^^^^^^ the oneration, but under these circumstances the tanno-gallic acid CSe of the Throat Hospital PharmacopcBia wdl 'ronc;\rrest the haemorrhage., ^^^^^^i^^Js the remedy should be slowly sipped at shoit interAals. 1 Chaasaignac, op. cit. p. 109. ENLARGED TONSILS. 73 During the act of deglutition the styptic fluid is worked into the cut surface of the tonsil, and the liiemorrhage is effectually restrained in all cases. In the worst instances the bleeding may recur again and again for a day or two, but it can at once be checked on each occasion by a prompt use of the tanno -gallic fluid. In most cases sucking ice^ generally stops the htemorrhage. In exti'eme cases, when the internal carotid has been laid open, the common carotid must be ligatured. With respect to the method proposed by Celsus, already referred to, of tearing out enlarged tonsils by the finger, it is worthy of notice that tliis method has been revived and practised with success by an Italian surgeon named BoreUi.3 He describes the proceeding as easy of execu- tion, and devoid of risk from htemorrhage. " The index finger," he remarks, "is placed behind the summit of the gland, and by working from above downwards with the nail, and making traction, the tonsil is detached from its bed. The organ can in this way be removed entire with much more ease than with the ordinary amygdalotome. A small piece, Avhich does not afford a sufiicient purchase to the finger in order to be torn away, is generally left at the inferior part. It only requires, however, to be seized with a forceps, when it can be separated by a slight movement of torsion." Finally, as regards the after-treatment of the operation, it may be stated that the wound usually heals spontaneously in a week or ten days. It is, therefore, only necessary to confine the patient to the house for the first few days, and to dii'ect him to avoid aU hot, hard, and irritating articles of food. Marsh-maUow lozenges (Throat Hosp. Phar.) often give great relief by forming a coating over the Avounded surface, and thus protecting it to some extent from the action of the ingesta. Occasionally the wound assumes an unhealthy aspect, and becomes covered with an ashy, aphthous exudation — sometimes almost membranous. This condition is most frequently seen when the hajmorrhage has been more copious and persistent than usual. Under these circumstances if the solid nitrate of silver be lightly applied daily for two or three days, the cut surface wiU rapidly become a healthy nicer. In other cases, Avhen there is marked constitutional dyscrasia, the wound may be slow m healing, and give rise to great pain in swallowing. I "Med. Times and Gazette." 1860, p. 631. - " Gazzetta Med. Ital. Prov. Sard." December 30, 1861. 74 DISEASES OF THE THROAT AND NOSE. The discomfort can, however, always be relieved m a fe^^ days by the application of mineral astringents .^/^^ piimenta of chloride of zinc or perchlonde of iron (Thi oat E Phar ). In conclusion, the only other evil conse- mience of the operation that can be feared is traumatic ui- dtion of the pharynx. I have never ^ J^^h ^ of this kind, but an instance is ^^^^^^^^^^f .J,^ ^^^g^^he Avhich resulted in oedema of the glottis and death. Jji the rar eveTof a^^^^ inflammation supervening, the practitioner should be guided by the rules which govern the treatment of traumatic pharyngitis. FOREIGN BODIES IN THE TONSILS.^ (Synonyms : Concretions. Calculi.) T f i^^ ^„._Corpora adventitia in tonsiUis. French 4- -Corps etrangers daiis les amygdales. Gevmmi iJ^.-Eremdkorper in den lonsiUen. Italian Eq.—Co^V^ stranieri nelle tonsiJle. Definition - Concretions and ccdcnU imUdded in the snbsZice Jihe tonsUs-the resrdt of a VfJ^rted m^d^Uon ^X^^aZral Secretions and of closure of the outlets of the lacunw. of the glands. ioloail -Wlien the- tonsUs are in a state of chronic infl^mtSn, the secretions of the follicles are frequently SfeTh character and augmented in amount As a aixcieu inounffi may become blocked up by tne ''"'S which omethnes becomes so inspissated as t. If fW Wiiess of a calculus.3 in some instances cal- attain the naiuness ox a r-herrv, or even culi have been met mth as large a a ch^uj 1 ,4 T1-.P nrpsence of calculi m tue touftiis j-"*'' X« of tousiU:/ calculi, ^lucb, mstead , „Di„t. des Sciences M^£.les.; JSd' SttlL^d V tbe 2 Foreign substances, wlucli aie v ^re considered m tonsils, dming their P^^^^^e thioug^^ the P^^ J? the article on " I^oi-ei,§^,^''^f Sdi 463 ^t seq. FOREIGN" BODIES IN THK TONSILS. 75 of being composed of urates, consist jjnucipally of phosphate and carbonate of lirne.^ Si/iiq)torns. — Th« symptoms of this disease are not, as a rule, A'eiy prominent. A slight pricking sensation in the throat is generally complained of, and when the concretions are large and numerous, there may be dysphagia. Occasionally small calculi are discharged spontaneously from the tonsil, causing shght soreness and bleeding. In most cases the concretions predispose to attacks of quinsy, whilst they not unfrequently cause ulceration of the walls of the cavity in which they are contained, and sometimes lead to the forma- tion of abscesses in the substance of the tonsU. In "thi-ee instances I have seen prolonged suppuration determined by the presence of a calculus, and the purulent discharge only ceased on the extraction of the offending substance. Pathologif. — Several writers have made an analysis of ton- sillar accretions, with a tolerably uniform result as to thfe composition of these morbid formations. They vary slightly as to the proportions of their chemical elements according* to tlie amount of hardness to wliich they attain. Thus they contain phosphate and carbonate of lime, a little iron, soda, and potassa, and when soft a considerable amount of water and mucus.2 men the lacuuc^ are filled by a grey, semi- fluid, or mortar-like matter, microscopic examination reveals the presence of epithelium, cholesterine, pus-corpuscles, bacteria, mould-fungi, and molecular masses or globules of chalk.^ Diagnosis. — The presence of concretions or calculi in the tonsils can only be recognized with certainty when portions of the foreign substances are either discharged spontaneously, or can be seen projecting from the lacunas of the glands, or can be felt with the finger or pharyngeal sound. Treafmeiit.—The only satisfactory procediu^e consists in the removal with forceps of the concretions or calculi ; or, should there be any considerable hypertrophy of the tonsils' the diseased glands must also be extirpated. In such cases the bistoury is sometimes preferable to the tonsHlotome, as the blade of the latter instrument cannot always sweep round or cut through the substance of, a large calculus. Pari?"' 117. Tv/r-i'^''°.??f • "^°^1- ^l'^"i Calciil TomiUaire," "Jom-n. de Chimio W ^l.«°Wnrzer: ''Buohner's Rep. f.'d. Pharn^.'^^^H 9 H Wagner : Ziemssen's " Cyclopedia," vol. vi. p. 970. 76 DISEASES OF THE THROAT AKD NOSE. Parasites in the Tonsils. As «ii appendix to this article it may be ^^^^^^'LS some scattered instances are on record in vluch ce tau parasites, such as l^y^^^^ds and trichocepkdi met with in the tonsils. Dnpuytreni ates the case o a ™\voman aged twenty-one, who for eleven months had liffpiPfl from attacks of inflammation of the tonsds ihe 1 t? Snd ""s^c^o^^^^^^^ swollen, and the surgeon having liicnW ahscess, plunged a histoury into the tumour. As a result nearly two ounces of watery fluid gushed out, she 'died soon ^ tr^ •m attack of erysipelas, an autopsy was made An o^ oi l tyst a di?^ Bimilar to that contained - he ton d, iTt as larae as a child's head, attached to the left kidney A^ aim st4nilar case, except that the patient -s a ^a^, - 4. 1 i.,r D-ivaine ^ and the same observer relates an ;:£ce in'wS 1™ nchocephalus was found lodged in the eft tonsd The parasite had probably attamed this situation foil b expelled from the stomach during the act oi vomiting DILATATION OF THE PHAEYNX. (Syn. : Pharyngocele. Pharyngeal Pouch). Latin i;^.— Dilatatio pharyngis. French ^Jr^.-Dilatation du V^^'^l'f- ... German ^.^.-Erweiterung des fechlundkopfs. Italian ^.V^.-Dilatazione deUa farmge. DEFiNiTi0N.-£«/«rj7e»z6ni of the cavUy of^^'f^'-^ eiS^S^L eMire drcLference, or at a partic^dar pa,t, ihaf a vouch or diverticulum is JormecL tX -From the nature of its surrounding and sup- poS^ —s, the pharynx ^^^J^J^ 1 "Le9onsOraies," t. ii. q . Tr^te des Ent°zoan^^B ^^^^^^^^^ 3 See a case figured m the aiticieou ^ DILATATION OF THE PHARYNX. 77 participate in this expansion. Dilatation of the pharynx, however, is more frequently confined to a limited portion of its circumference, and the stretched membrane, by pro- iectin<^ in one or other direction, constitutes a ' pouch or diverticulum. Such a protrusion really deserves the name of a hernia, as it consists of the mucous and sub-mucous coats only, which pass out between the fibres of the muscidar tunic of the pharynx. Diverticula of this nature cenerallv extend backwards and downwards, and make their way between the oesophagus and vertebral colmnn, whilst occasionally they project laterally and form a tumour at the side of the neck. Eokitansky^ conceives that diverticida sometimes result from small foreign iDodies, such as cherry stones, having become lodged at some part of the pharynx. The etiology of their formation is not clear, but it seems most probable that they arise from a weakness at some part of the 2>liaryngeal walls, Avhich causes the membrane to yield when any unusual strain is applied. I have met with three cases in persons who had resided for many years in troi3ical climates, and in whom there were other symptoms of relaxation. A habit of "bolting" food is lilcely to disturb and vitiate the functions of the involuntary muscles of the pharynx and oesophagus, by thi-usting more substance into the channel than can be carried down without stoppage ; and I have ascertained that there was carelessness and hurry in eating in several of the cases of pharyngeal dilatation that have come under my notice. Finally, diverticula of the pharynx have occasionally been met Avith as congenital mal- formations, and in such cases it is possible that they may be relics of the branchial clefts.- Symptoms. — The prominent symptom of a pharyngeal diverticulum is dysphagia, i.e. difficulty, unaccompanied with pain, in swallowing. Portions of food become arrested from time to time in the pouch, which thus forms a temporary solid tumour in the neck. In this way, Avhen the diverti- culum is situated between the vertebrfe and the gullet, the obstruction may be so great as to close the passage. In many cases the phenomena simulate those of stricture of the cesophagus. The diverticulum, however, becomes emptied after awhile, and the occurrence is followed by a great temporary relief to the patient. Thus the symptoms vary ^ " Pathological Anatomy " (Syd. Soc. Traus.), vol. ii. -g. 12. ^ = See a ca.se by MajT in the " Jahrbuch z. IGnderheilkunde IV. 3, p. 209. 18G1. ' •78 DISEASES OF THE THUOAT AND NOSE. considerably at difierent periods. The mechanism T.y whicli the contents of the p(A;ch are voided is not well understoo.1. The accnmulation of food is ejected so that the patient thinks he is vomiting, bnt the process is imaccompamed l^y retclimg or nausea. In some cases the receptacle discharges its^ con- tents so gradually that a kind of rumination ^o he established. In other instances fragments of food hnd eir way into the larynx whilst passing from the ^^verticu urn, and oive rise to severe attacks of spasm or to fits of cough- in. i 8uch foreign matter may even find its way into the lower parts of the air-passages, and give rise to bronchitis or pneumonia. Sometimes it happens that the diverticukun becomes i^uflamed, and a cure results from adhesion of the oSoTite walls of Ihe sac. Such inflammation may ^o-ever lead to sloughing and extravasation of food into the po..t- plwyn-eal connective tissue. Cases of pharyngeal pouch may &e for many years without ^^^^ ' svmptoms. I have seen several examples where the d sease hybeeu going on for twenty or thh:ty years, and was lately consulted by a" patient in whom the symptoms had existed rX-one^years. In none of these cases was the nutntion seriously affected. In most of them the patients had hved Ponsiderable period on Uquid food, and the oldest of ''XSw -The opportxmity for a post-mortem examination rarSv tisef but in a case reported by Bokitansky,^ where he s™^^^^^^^^^ existed forty-six yeai-s, the «s mem- branJof the back of the mouth was hickened, wdiilst that nf the uDDcr part of the larynx was cedemaLOus. On a level wi^^ t^ nf rior constrictor of the pharynx the mucous membiane was prolonged through the fibres of th^ mu^^^^^ rlWprticulum about two inches m length. Ihis poucn into a ^euular tunic of the cesophagus m a4«t£iiE:i.'iS:s Jing extent of tlus -^t^'tl,, 1 See a Preparation m the St Ueor e^s i^ ^^^^ No. 14. The patient, ffit. 63, ^^^^^ of the laiyo-^- DILATATION OF THE PHARYNX, 79 Diagnosis. — Au uniform dilatation of the pharynx can readily be ascertained by digital and laryngoscopic examina- tion. A pharyngocele may generally be diagnosed from the history of the case. The difficulty of swallowmg, the sensEition of a foreign body in the throat — augmented after meals, the presence of a soft tumour on the outside- of the neok, -which can be dissipated by pressure, and the frequent ejection of small portions of undigested food, are all phenomena almost pathognoihonic of the condition. By the use of a sound the form, size, and direction of the diverticulum can usually be determined. Prognosis. — Enough has already been said to show that this affection is more frequently productive of inconvenience than of any immediate danger, although ia some cases life is no doubt shortened by the condition. The chances of cure are extremely small, and little result can be expected from remedial measures, except when the pouch is at the side of the pharynx. Treatment. — Where there is slight general dilatation, in- dependent of stricture of the oesophagus, increase in the contractile power of the constrictors may occasionally be ob- tained by the frequent application of faradism and galvanism. In the case of a diverticulum such treatment is unavailing, but if the pouch be situated laterally, so that pressure can be brought to bear on it from the outside of the neck, the patient is enabled to empty it himself,^ and thus avoid any serious symptoms. In such cases swallowing may be greatly facilitated by pressure Avith the finger on the neck opposite the diverticulum whilst eating. Under these circumstances the morbid condition may be present for an almost uiilimited period without causing any Ul effects beyond an inconvenience during meals. In several in- stances I have been able to give great relief to patients bv directing them to wear a stifi' stock with a pad over the sent; of the diverticulum. When, however, there is danger from repeated suffocative attacks, or from inanition, it will be necessary to try and avert the peril. Should the aperture ot the pouch be small, and be visible either by the unaided eye or by the laryngoscope, an attempt may be made to produce cicatricial contraction of the opening by the local application of galvanic cautery. If these measures fail an operation sunilar to 03sophagotomy might be undertaken, and fronf ^ ^"^-'^^ ^"^^fif^ °* Surgeons' Museum, removed iiom tJie body of a man ret. 90. "^uvtu 80 DISEASES OF THE THROAT AND NOSE. the poucli excised. This having heen done, the edges of the mucous membrane would have to be carefully brought together and secured by stitches. After such a P^'^cedure in order to avoid traction on the wound, it would ^^^cessaxy to feed the patient through a tube until union had taken place. CANCEE OE THE PHAEYNX.i Latin iJg.— Carcinoma pharyngis. French iJg.— Cancer du pharynx. German JJg.— Krebs des Scnlundes. Italian JJ^.— Cancro della faringe. Definition —Primary malignant disease of the pharynx, cienerally caudnrj death ly starvation, Ut sometimes hy liccmorrhage. Etiology.-'Pnm^^y mahgnant disease of tte pharynx may ori^i ate in the walls of that cavity, or m the tonsils. It is rare in the pharyngo-oral space, but very common in le loZ port on Jf the canal, where it generaUy first ^l oWty which surx'ounds the etiology of cancer ui n^ber mSs holds good as regards the pharynx, and heredity fL^ only known influence about which there is no trTLToiS^^^^^^^^^ articulation indistinct, and Ti, this article, the disease i« conddered ^ so -lat^^^^^^^ -^S-^SS^^^^r^t e^eetio. .ith disease. °^.'waS: "The Natvu-e and Treatment of Cancer." 1846, pij. 265, 267. CANCER OF THE PHARYNX. 81 the exiDectoratiou fetid. The atfectiou causes constant jaain, which is greatly increased on attempted deglutition. The pain becomes greater when ulceration commences, and often darts into the ear. As the disease advances the respiration becomes obstructed, and great inconvenience is often expe- rienced from the posterior nares being blocked up. When the cancer is situated in the pharyngo-laryngeal cavity, the symptoms, course, and termination of the affection are almost identical with the phenomena attendant on malignant disease of the oesophagus, and the disease generally runs a slower course than Avhen it occurs in the j^haryngo-oral space. In the lower situation there is dysphagia but often no odynphagia. As a consequence, the patient takes more food, and lives longer, and more time is allowed for the development of the characteristic cancerous cachexia. The constant expectoration of a frothy mucus is a character- istic _ symptom. The disease sometimes leads to per- foration of a vessel, from which fatal htemorrhage may ensue. Pathology. — 'ken the disease is situated in the pha- ryncjo-oral cavity, it is usually of the scii-rhus variety, pre- senting, as Delpech^ remarks, a considerable resemblance to malignant disease of the rectum. Physically the first sign of scirrhus of the upper part of the pharynx is a hard, imperfectly circumscribed mass, occupying a variable extent of the sub-mucous tissue of the tube, and invested by the mucous membrane, which in the early stages retains to all appearance its normal character. At this period a hard elevation can usually be felt, whilst pressiu-e does not, as a rule, occasion any pain. As the malady progresses the indu- ration gradually extends over the greater part of the pha- rynx, and may involve the veil of the palate and the orifices of the posterior nares. Ulceration next commences, and extends over the whole of the affected part, presenting a reddish or greenish-white surface covered with fetid exuda- tions, and, later, numerous fungous elevations arise from the surface of the ulcer. Tumefaction of the cervical glands about the angle of the jaw generally takes place at an early period. I have seen many cases of cancer in which the upper part of the pharynx and the epiglottis were both attected, m which it was impossible to determine in which part the disease originated. A case of this sort was ' " Diet, des Sc. M6(i." Paris, 1812, vol. iii. j,. Gil. G 82 DISEASES OF THE THEOAT AND NOSE, exhibited by me at the Pathological Society some years ago,i and a typical example has been described and hgui-ed _ by Mr. A. T. Norton.^ Cancer of the pliaryngo-laryngeal cavity is a very comuion disease It is usually of an epitheUomatous character, thou-h scirrhus occasionally occurs. It commonly com- mences just beloAV the level of the arytenoid cartilages. In the earlier stages, pale greyish-^Yhite s ough-lilce vegetations <;an be seen with the laryngoscope at the lower part ot the pharynx, surrounded by a z5ne of bright red, swollen, mucous membrane. Sometimes the disease commences m the thyroid fossa, but in nearly all cases,_ whether originating .at the back or the sides of the pharynx, it extends round the .cavity and reaches the air-passage o-resses, considerable tumefaction of all the tissues takes llace but the cervical glands are not generally enlarged. Diarinosis.-'n^Q cUagnosis of cancer of the pnarynx seldom presents any difficulty, although cases are on record which syphilitic condylomata 3 and guminata were Mistaken for malignant disease, ^he use of iodide o mercury and iodide of potassium respectively cuied the cases referred to, and demonstrated the error of diagnosis A fibSma may also be mistaken for encysted cancer but its peduncle generally serves to distinguish it, and it shows no disposition to ulceration. Procinods.—Th.Q disease must necessarily end m death, and the only doubt which can exist in the prognosis relates to the que^stion as to how soon the malady may be expected to p?ove fatal. The duration of life is generally much shorter when both respiration and deglutition are aftected than when swaUowing alone is impaired. rrea!!«ie«i. -Palliative measures alone can be adopted. Shruld ^s iration be dangerously incommoded, tracheotomy tXo ten obtain a prolongation of life, whdst inability to ^Idlow list be met by the use of the ^V^^^^^' ^ hv the administration of nutritive enemata.^ imailj, an .atCpt may be made to prolong life, by resorting to 1 "Trans. Path. Soc." vol. xLx. p. 71. 3 SJei^'^pll^ques mudueuses hypertroph. des Amygdales;" (New Syd. Soc). 1808, ie'the'Jrticlo on " Cancer of the CEsophagus," in tins work. CANCER OF THE TONSILS. 83 (-t'sopliagDtomy, liereafter described. Sciii'liiis, in tlie lower l^art of the pharynx, is the form of cancer most iikely to fiu'nish a suitable case for such an operation. Cancer of the Tonsils. This is a rare disease, but cases have been reported by Veliaeau,! Maisonneuve," Lobstein,^ Lennox Browne,^ tfec. Most of the reported instances belonged to the encephaloid variety, the disease being in some cases primary and in others due to extension from adjacent parts. I have met with seven cases of cancer of the tonsils, five of which were encephaloid, and two scirrhous. The following short sum- mary shows the sex and ages of the patients : — Encephaloid. Scieehous. Female. Male. Female. .^t. 43 . . 1 2Et. 47 . . 1 ^t. 34 . . 1 The average duration of life after the symptoms appeared Avas seventeen months, the maximum having been twenty-five, and the minimum nine months. One or both tonsils may be the seat of the malady, which commences in the form of a tumour situate in the substance of tlie gland, and at a more advanced period presents an ulcer which there is little diffi- culty in recognizing as cancerous.'^ Chronic induration and hypertrophy of the tonsils may sometimes simulate malignant disease in the early stages, but the history and progress of the case, together with the age of the patient, afford a definite clue to the nature of the malady. Hypertrophy of the tonsils generally commences early in life, and is rarely met Avith after the fortieth year. Cancer, on the other hand, is seldom met Avith before the adult period, whilst all the symptoms become aggravated witli comparative rapidity, and a fatal termination f|uickly ensues. When the cancer IS confined to a i^ortion of one or both tonsils, these organs I Jl-iegeois : " Diet, des Sc. Mecl." Paris, 1864, vol. iv. p. 26. 18.59 Societe de Chirurg."— " Cancer des Airiygdales." I "Anatomic Pathologiqne." 1829, vol. i. p. 429. - T A '^cl its Diseases." London, 1878. ' Lebert: " Traite des Mai. Cancer." 1851, p. 422 84 DISEASES or THE THROAT AND NOSE. may be excised, with tlie occasional result of ' aftbrdiiig tlie patient a few months respite. Cases which clinically are considered cancer, on post- mortem examination are often found microscopically to he of the himphomatous or hjmplw-savcomatous character A remarkable instance of this kind has been reported hv Dr Moxon,! ,yMch the left tonsil, the lymphatic olands, and the spleen were all the subjects of a brain- tL growth. These tumours consisted for the most part of cells, kept together by a network of fine fibres, ihe cells were larger^ban lymph-cells, and tl- interior o each was filled with a large nucleus and many ^^^^1^° ^^^^^^^^ have met with a somewhat similar instance m a patient a^ed fifty-seven, in whom both tonsils and the lymphatic gCds 0^ both' sides were affected with snndar cellular °rowths. In this case the development of the tumoui tvas checked for a long time by subcutaneous ^ijections f acetic acid. I have also seen two cases of simple lymphoma 0 ne tonsil, in patients aged respectively twent^seven and thirtv-two In each case life was prolonged by lepeatul Smova l of diseased structure, but the affection ultimately ;red fatal from dysphagia and consequen mai« la my three cases of lymphomatous disease of the tonsils tlie patients were men. NOMALIGNAI^T TUMOUES OF THE PHARYNX. Latin ^r/.— Tumores non maligni pharyngis. J^tc/rl^.-Tumeiirs non malignes du pharynx. Tumeurs b6nignes du pharynx. Oerman iJ^.-Gutartige Geschwiilste des Schlundes. Italian j;^.— Tumori non maligni deUa iaringe. gi^ape,_ «^^^^^\f 7,1,^^^^^^^^^^ Luschka,"- Sommerbrodt,^^ ^°foXrsCels iV S cases of pharyngeal papilloma. lt:"rof fibro^us structiu-e -cl f ty ^^^^^^^^ a£o° b^en met with in this region. Barnard Holt 1 "Trans. Path. Soc." vol xx. p. 369. 2 Virchow's " Ai-cHv." vol. 1. p. 161- 3 Ibid. vol. U. p- 136. 4 "Traus. Path. Soc." vol. v. p. 123. NON-MALIGNANT TUMOURS OP THE PHAHYNX. 85 reconlcd a case in Avliich a fatty tumour springing from the left side of tlie epiglottis and pliarynx hung down into tlie esophagus for nine inches. The patient was eighty years of age, and was nearly suffocated on one occasion by "the mass heing propelled upwards, and occluding the larynx during the act of vomiting. The growth was not remoA^ed during life, and the man subsequently died suddenly Avhile smoking. Two j)reparations of pedunculated tumours removed from the pharynx during life are contained in the Eoyal College of Surgeons' Museum.^ The first of these is a lobulated mass, about two inches long and half-an-inch in diameter, and resembles a mucous polypus of the nose. It Avas attached by a very slender pedicle, not thicker than ordinary tAvine, just behind the tonsil. In the other case the diameter of the gTOAvth is considerably greater. The tumour is of irregular siDherical shape, and appears to be of a fibroid nature. Its surface is covered by mucous mem- brane^ but is ulcerated at sevei-al points. The mode of attachment is not quite clear, but the tumour seems to have been attached by a stout, strong pedicle to the Avail of the pharynx. Voltolini^ reports the case of a smaU fibroid groAvth, about half the size of a pigeon's egg, springing from -the posterior Avail of the pharynx, whilst Fischer ^ describes a tumour, apparently sarcomatous, which extended from the base of the skull to the cricoid cartilage. According to Busch * such tumours may take their origin from the mucous mem- brane, from the connective tissue posterior to it, from lymphatic glands, or from the periosteum covering the vertebral column. Finally, it may be remarked that growths originating in the naso-pharyngeal cavity or posterior nares often descend into the pharynx proper. Synvptoms, ifc. — The mala symptoms produced by pharyngeal growths are those due to interference by the morbid mass Avith deglutition or respiration, and they vary Avith the size and position of the tumour. Small excrescences on the fauces or tonsils cause little inconvenience beyond an occa- sional sensation of a lump in the throat in sAvaUowing. In ■some cases the tumour may give rise to troublesome cough, if lying in contact Avith the larynx or epiglottis. The diagnosis •of growths in the pharynx can generally be made without ' Nos. 1090 and 1091. * " Galvanokaustik," p. 226. ^ " Wiener Mediz. Wocliensoluift." 1866, No. 61 "Berliner Chai-ite-Annalcn." 1857, vol. viii. p. 1. 86 DISEASES OF THE THROAT AND NOSE. difficulty on examination with tlie unaided eye or by tlie aid of tlic laryngeal mirror. , Treatment.-8m^ll growths, such as papiUomata, may be torn off by strong forceps, or can ^^^^,.^^^^1^ ^^^^^f ^^ar the application of London Paste (Ihroat Hosp Phar • Larger formations, if peduncrrlated, may be ^'^^^J^^^^^^^ ceps^ by galvanic cautery, or by the ecraseur, ^he base ma he ekcicled by a ligature, and the tumour then be cu off m th the knife. In the case of growths of such a size as to fill ^ areat part of the pharynx, care must be exercised m then remova Tl us we\ee that in Holt's case the mere displace- rn^t of the tumour upwards was sufficient to produce suffo- Xn bytcluding tlJ larynx. Should tl- attachmen^^^^^^^ the growth be extensive and vascular, «^<=^X ^ ^^^^ with the risk of asphyxia from hemorrhage, ^nde U^^^^^^^ cumstances it has been recommended first ^ P i^^e W^^^ otomv and as soon as the patient is able to breatlie tree 3 tWh the tube to remove the morbid mass m the pharjmx.^ SYPHILIS OF THE PHARYNX. Latin ^J^/.— Syphilis pharyngis. French Eq.—Ajigme syphilitique. German JJg.— Syphilis des Schlundkopfs. Italian Eq.—Aagina siaiitica. DEFiNiTioN.-%jA^Vi. attacJdng the pharynx and present- inf te iZnonJi met mth in the three stages of thar disease tvhen affecting mucous surfaces. Miology.-SjV^ of the pharynx may l;;;tlj^^-^}f^\^f The f ^"j'^'y '''n' ^,^^1' on one of the tonsils, owing, no- tubt af DeLs"^^^^^^ the structure of these glands, t hcume 0? which are likely to receive and retain tt syphStic virus when introduced nito the throat. 1 Dm-ham- " Holmes' System of Sm-geiy," vol. iv. p. 489. Sod iu the a- -f-red'for fui-ther infoxna^ation. SYrmLIS OF THE PHARYNX. 87 Diday^ explains tliat the disease should theoretically be more common among females, and my own exijerience tends to confirm his hypothesis. Thus, out of seven cases of primary syphilitic sores -which I have met with on the tonsils, six of the patients were A^omen. In Diday's own cases, how- over, the aflection was divided equally between the two sexes ; whilst Desnos," from the examination of a mass of statistics, concludes that the primary sore is not more fre- quent amongst females, and explains 'the mode in which the disease is established in this situation in males. The rarity of chancre of the pharynx may be estimated from the fact that of 673 examples of chancres in all situations, not one was found behind the anterior pillars of the fauces ; whilst of seventy- seven primary sores of the buccal region only one had its seat on the tonsil.^ Secondary and tertiary syphilitic phe- nomena in the pharynx are among the commonest local manifestations of the disease, when it has become constitu- tional, as the result of inoculation or heredity. As Swediaur * observed long ago : " When the syphilitic virus is absorbed into the mass of the blood, in the majority of cases it produces its fii'st effects on the throat." According to Martelliere,^ the causes which commonly give rise to the ordinary acute and chronic diseases of the pharynx determine the specific disease to attack that part in syphilitic persons. With respect to the frequency with which the throat becomes the seat of lesion in constitutional syphilis, the same authority states that, on examining seventy-two patients affected with the malady, he found only twenty-one in whom the pharynx did not pre- sent some characteristic alteration. ^ Sijviptoms. — The symptoms of syphiHs of the pharynx vary, subjectively and objectively, according to the phase of the disease imder which they appear. In primary syphilis but one local lesion can occur, viz., the product of direct inoculation— the chancre. In the secondary stage, the disease may present itself under the form of erythema or mucous tubercles (condylomata). At the third period, like- wise, we may find two distinct sets of phenomena in different cases, viz., ulceration and gummata. The sequel of ulcer- _ ' " Compt. Eendus de la Soc. de Med. de Lyon." 1861-62 t 1. p. 45. ' * 'Pharyn^tis Syphilitica." 1801, t. ii. p. 147. 'lO "^^ ^'^^"^^ Syphilitique "—" These de Paris." 18o4, No. 6,. " Ibid. p. 9. 88 DISEASES OF THE THROAT ANU NOSB. ation is often contraction of the tissues of the pharynx, and narrowing of its canal and the passages leaduig Irom it. 1. Although the primary syphilitic sore is rare, iJiaay states that he has met with eight cases, and believes that the chancre, when occurring iii this situation, is generaUy overlooked both by patient and practitioner. 1 have myself seen seven cases in which no reasonable doubt could be entertained as to the nature of the disease ; but in two of these the diagnosis would have been very difficult from the physical condition alone, ihe local appearance is generally that of an ulcer superficia but surrouided by an elevation of slightly oedema ous mucous membrane. By the touch it can be ascertained to ha^e an indurated base, and in most cases there is very manifes swelUn- of the glands about the angle of the jaw. The characters of the hard chancre are not, however, always so w,n maSed. Thus, in a patient of Diday s"- a mere super- ficial erosion of the left tonsil, with sUght glandular engoije- ment, was soon followed by the phenomena of secondary svphilis. In two other examples given by the same wi-itei a pha-edfenic form was assumed by the chancres, and deep, nheal hy-looking ulcers extended rapidly for several days, i is only in these cases that local or constitutional symptoms such as pain, stiffness of the jaw, and PPe^ia -are hkely to attract the notice of the patient. As a rvile. the chancre runs ils couL and heals without making much impression on the health or sensations of the person affected. 2 a.) Erythema of the pharynx is a very comm n secondary manifestation of syphibs. Thus, out of lU women affected constitutionaUy, PiUon noted the affection "iL'^foi^mptoms of the affection are those of an ordi- nary soifthroat, viz., dryness of the fauces, fffj^ deglutition, and occasionally a mdd pyi^exia^ ,?",^ ? e the throat at an early period, the veil of the palate, tne ndki of the fauces; and the tonsUs are seen to be P f w rpJl Tn a day or two, however, the erythema r ra'cWded'teilLIy to U^it ^^^^^ n iafliiP,l nnrcins to a certain portion of the puaiynx, to .y„n„*ical'' ™pmeut , It may fflt tho fmces on eaeli side and tlie back ot thy 1l:^n^-t:^nJui snddenly at the anterior pillavs, or .t . 2 Ibid Ibid. . . Des Exa^th^ios SypWUtidues Tlxese de Paris." 1857, p. 19. SYPHILIS OF THE PHARYNX. 89 may cease at tJie centre of one tonsil, whilst extending over the whole of the opposite side. The redness never fades away gradually into the healthy tissues, but is bounded by a very distinct line of demarcation. According to Pillon,! a species of erythema manifests itself in the throat at a later period of secondary syphilis, which is characterized by a greyish tinge, and by granulations on the surface of the mucous membrane. (b. ) Mucous patches (syn : mucous tubercles, broad condy- lomata, ^3/a(2?s) are present in the pharynx in a large proportion of cases of secondary syphilis. When occurring as the result of heredity, they are found in the upper part of the pharynx and on the fauces soon after birth. In adults they are generally seen on the pillars of the fauces and the veil of the palate. At first they are very slightly elevated, are of a circular or elliptic form, and nearly always symmetrically situated on each side of the throat. At a later stage they become the seat of shallow ulcerations, their surface changes to a greyish-white colour, and their edges become uneven. In six or eight weeks they generally disappear spontaneously, their former position being marked by a slightly deeper shade of the mucous membrane. While they last they cause considerable soreness of the throat, especially on deglutition. The skin manifestations associated with condylomata are usually of the nature of syphilitic papidte, though some of the other early syphilides may be present. 3. (a). The ulcerations of tertiary syphilis may be divided into two varieties, viz., siqjerfidal SLndj^ej-forating.^ The super- ficial ulcers most frequently occupy the veil of the palate, but they are sometimes seen on the pillars of the fauces and the tonsils. They extend with great rapidity, but generally attack only the superficial tissues. These ulcers are sometimes of serpiginous form, and are generally covered with an ichorous pus; but if this is cleared away the base is seen to be pale and smooth, with here and there some fungous granulations. The edges are iri'egular and jagged, and cracks or fissures sometimes pro- ceed from them and extend for a considerable extent into the surrounding tissues. When these ulcers occur in scro- fulous persons they are often very intracta,ble, and the ' Loc. cit. p. 13. ^ ' See Lancereaux : " Treatise on Syphilis " (New Syd. Soc). 1868, 90 DISEASES OP THE THROAT AND NOSE. affection has been called scrofulo-syphilltic, but there does not seem any adequate reason for recognizing this complica- tion as a separate disease. Perforating ulcers probably always originate in the softening of gummata. They may be situated on any part of the palate, tonsils, fauces, or back of the pharynx, and, as Lanceraux i says, " they gain in_ depth what they lose in extent." Commencing by an inflam- matory redness, after a few days a spot of a dirty white colour appears at the centre of the inflamed patcli, and at this point the tissues beneath become liquefied. The de- structive action extends deeply, and attacks cartilage, perios- teum, and even bone. Thus the palate bone, the basdar process, and the bodies of the vertebraj may become necrosed or carious. In a case ^ under my own care, where there was a deep ulcer on the posterior wall and right side of the pharynx, the patient lost more than a quart of blood, and, as she soon afterwards expectorated the transverse process of the second cervical vertebra, the hasmorrhage was beheved to come from the vertebral artery. Lesions of the brain and spinal cord may also result from the ravages of syphdis on the osseous walls enclosing these nervous centres. If the skm is affected in this stage of the malady, it is generaUy rupia that occurs. The constitutional symptoms which accompany tertiary syphdis often denote a serious dyscrasia, and loss of appetite, emaciation, and hectic sometimes carry off the patient. Tertiary syphilitic ulceration, destroying the back of the palate, is not unfrequently the result of heredity. The idceration breaks out fresh from time to time, and the patients, when brought for medical treatment, vary in age from three or four years to fifteen or sixteen. In later years it is not always possible to distinguish between hereditary and acquired disease. When the disease attacks the pharynx m this way, the anterior part of the mouth escapes, and the permanent central incisors are not notched. (b ) Gummy tumours of various parts ot the body are amongst the most characteristic phenomena of the advanced stage of constitutional syphUis. In the pharynx they are generally situated under the mucous membrane of tne Josteriorwall, but are sometimes seen in the soft palate.-^ At first they are small and .insensible, and they usually make very slow progress. As they increase the mucous membrane covering them becomes injected, and presents a violet-red 1 Op. oit. p. 305. 3 "Trans. Path. Soc." vol. xx. p. 3 See a case by MarteUi6re : Op. cit. p. o8. SYPfllLIS OF THE PHAllVNX. 91 colour. At the same time, the ghxnds about the angle of the. jaw commence to enlarge. After existing for a variable time the gumma arrives at a stage of softening, and perforates the mucous membrane. It maj'- either give rise to inflam- matory tumefaction of the superjacent tissues, and cause a common form of tertiary ulceration, leaving no trace of the nature of its origin, or it may perforate the mucous membrane at se-\-eral spots, and give slow exit to a continuous discharge of ichorous pus. "When the -gumma is situated in the soft palate the tissues on both sides are eaten through. Thus a fistulous communication is established between the mouth and the posterior part of the nasal cavity. The edges of such fistula?, or ulcers are generally cleanly cut, and cicatriza- tion proceeds very sloAvly In these cases there is generally a disagreeable nasal voice, and in swallowing, fluids often pass up into the nose. When gummata are seated at the back of the pliarynx, they sometimes originate in the jaerios- teum of the vertebral column, and, after becoming enlarged and softened, perforate the mucous membrane. ^ The termi- na,tion, however, of gummy tumours is not inevitably ulcer- ation,^ for they are often reabsorbed under the influence of sj^ecific treatment. When the ulcerative process attacks both the posterior waU of the pharynx and the soft palate, the two surfaces may be brought into apposition by the inflammatory tume- faction, and union of the opposing ulcerated surfaces some- times takes place. Dr. Schech^ believes that cicatricial contrac- tion_ of the pharynx is not only the result of deep and ex- tensive ulceration, but that it is frecjuently due to superficial erosions and denudation of the epithelium. According to that observer, it is not necessary that the ulcers or erosions should occur at the same time on the pharynx and palate, although, as a matter of fact, they are more often simul- taneously present. Schech considers that the perforation of the palate greatly favours the 2}haryngeal stenosis. The loss of tissue and the consequent altered muscular rela- tions cause a diminution of the normal tension of the soft palate, so that its mobility is impaired, and it cannot recede from the pharyngeal waU as easily as in healtli. The base of the uvula thus often remains in contact with the wall of the pharynx for a considerable length of time— especially when the patient is recumbent. Schech further points out that ^ MarteUiere : Op, oit. = 'jDeutHohcs Arcluv fur Kliu. Meclicin." 1876, xvii. Nos. 2 92 DISEASES OF THE THROAT AND NOSE. tlie exit of air through the perforation favours adhesion by lessening and diverting the current of air which, in coughing, sneezing" and hawking, tends to break down the recently- formed adhesions in those cases where there is no opening in the palate. The isthmus of the fauces loses its normal arch, and the velum, or whatever may remain of it, is draAvn back- wards by white cicatricial tissue radiating from the hard palate to the posterior wall of the pharynx. Sometimes the communication between the nose and the pharyngeal cavity is entirely cut off, whilst only a minute opening leads to the lower part of the pharynx. When the posterior nasal passage is completely occluded, the sensation m the nose is often most distressing. There is a constant feehng of dry- ness and stuffiness, the patient is unable to clear liis throat, and suffers from loss of smell and taste. When the passage to the lower part of the pharynx is contracted, there is diffi- culty of swallowing and dyspncea. It not unfrequently happens that the entrance of the larynx or orifice of the oesophagus is greatly contracted, and then the symptoms are even more severe. Prognosis —The prognosis is in most cases favourable as regards life in the early syphilitic affections of the pharynx, but serious in relation to the later manifestations. Secondary phenomena often pass away without treatment, and are not dangerous whHe they last. Should erythema extend to the larynx, it does not give rise to cedema of the glottis, nor to any serious sweUing of the Hning membrane. The same remark applies to mucous tubercles. The lesions of tertiary syphilis, however, must be attentively considered m each case before arriving at a decided prognosis Death may result from the destructive ulceration of the coats ot a large vessel; and in less serious cases, cicatricial narrmvmg of the air-passages, or destruction or _ perforation of the soft palate, may occasion permanent injury to the functions of the degluto-respiratory canals. Extensive ulcerations mav lead to caries of the neighbouring bones, and in- duce death by establishing a persistent cbain on the con- st tution. Should the base of the skull or vertebral column be ome diseased, fatal lesions of the 1^-- --^^^^ sninaHs may, as already remarked, be provoked The r^e m^y ^each the larjnx, and gi- rise to t^ie dangers hereafter described under "Syphihs of the Larynx. Dkujnosis.--The diagnosis of a primary sypMitic sore SYPHILIS OF THE PHARYNX. 93 situated in the pharynx is beset with uncertainties. Not only is it a difficult and delicate matter to ascertain the history of such cases, but the local ap^jearances are by no means pathogno- monic. On this account it is generally impossible to arrive at a decided opinion until the development of constitutional phenomena, and the results of treatment combine to confirm our lirst suspicions. If a suspicious ulcer remain obstinate to all internal remedies and local appHcations (such as nitrate of silver and nitrate of mercury, ifec.) for four or five weeks, we may feel almost certain as to the specific origin of the disease. If secondary syphilitic symptoms subsequently arise, still less doubt can be entertained respecting the nature of the primary ulceration. The diagnosis of syphilitic erythema of the pharynx depends principally on the simul- taneous appearance of the same eruption of the skin, and on its symmetrical disposition. The pale, raised, symmetrically situated tubercles, surrounded by the brightly congested mucous membrane, can scarcely be confounded with any other condition. When these guides are not present, the history of the case, and the presence of the cicatrix of the primitive sore must be ascertained in order to arrive at a definite opinion. Tertiary ulceration is sometimes with diffi- culty distinguished from cancer ; but in the latter disease there is generally more thickening and less destruction of tissue, and the local colouring is much brighter. An ulcerat- ing gumma may resemble cancer for a time, but the progress of the case soon reveals its real nature. In pharyngeal phthisis the ulcers are generally very small, the dysphagia is much greater, and there is generally a very high evening- temperature, which is altogether absent in syphilis. Treatment. — Should a chancre of the tonsil be positively diagnosed, the surgeon -will either adopt, or abstain from, mercurial treatment, according to his views with regard to the action of that drug. EmoUient gargles give relief, but should the primary sore present a phagedasnic character, recourse must be had to cauterization with the acid nitrate of mercury. Secondary syphilitic affections of the pharynx do not usually require any constitutional remedies. For the last eighteen years I have seldom employed any specific treat- ment for adults. Under the use of local remedies the symptoms rapidly disappear, and I have rarely met with tertiary phenomena in the throat amongst tho.se whom I previously treated for the earlier manifestations. Hence it 94 DISEASES OP THE THROAT AND NOSE, is probable that the non-use of mercury does not increase the risk of a farther development of the disease. Should the early phenomena of constitutional syphdis, however, prove intractable, mercury may be administered. Under these cir- cumstances, I generally give it in the form of cyanide of mercury.i When the early phases of syphilis are seen m newly-born children, mercury, however, acts most bene- ficially—especially in the form of grey powder. The reso- lution of erythema may be hastened by painting the part with a solution of chloride of zinc (20 grs. ad Sj-), and mucous patches are best treated by local applications of tincture of iodine. In the tertiary stage of syphiUs our chief resource is the internal administration of iodide of potassium. Under the specific influence of this drug foul ulcerations become clean and healthy, whilst local tumefactions a.nd gummata are resolved and reabsorbed. It is best to begin with five grains three times a day. The effect should be watched, and the dose may soon be increased witli advan- tage to ten grains three times in the twenty-four hours. Thirty grains a-day is generally sufficient, but m some cases as much as ninety grains may be given daUy with advantage. In most cases it is advisable to continue the iodide of potas- sium for 'some time after all local phenomena have disap- peared, whilst on the slightest sign of any new manifes- tation the drug shoidd at once be resumed. In those cases where iodide of potassium appears to produce only a tempo- rary effect, and where recurrenees are frequent, recourse may be had to the administration of small doses of cyanide of mercury I have, however, seldom found mercury successful where iodide of potassium has failed. Locally, the treat- ment of tertiary syphilitic lesions of the pharynx varies ac- cording to the phenomena present. Ulcerations, if indo_leni, are best treated with a solution of sulphate of copper (lo grs. ad 51.) ; whilst, if spreading, tlie progress of the sore can 'eneraUy be checked with the solid nitrate of silver or ackl nitmte of mercury. When there is con raction of he passages leading from the pharynx, the canals must be iXl with bougies, forced open with dda^ors, or en arged bv the destructive action of galvanic '^''fY\.n?tion o?the burg 3 has also recommended excision of a portion, of the Acaciffiq.s. M.Ft.pU. One pm twice daily. (Tlu oat H3.p. ir-im.) ■2 " Wien. Mediziu Prcsse.' 18/6, No. 36. PHTHISIS OF THE PHAEYNX. 95 cicatricial tissue. The use of bougies is, perhaj^s, on the whole the most satisfactory method of treatment, as forcible extension or destruction of tissue is generally soon followed by fresh cicatrization. In any case, however, though great relief can be afforded to the patient as long as he remains under treatment, no cure can be predicted, as the stenosis always returns when mechanical measures are suspended. PHTHISIS OF THE PHAEYifX. Latin Ecj. — Phthisis pharyngea. French Eq. — Tuberculose miliaire de la gorge. German Eq. — Mihartuberculose des Pharynx. Italian Eq. — Tubercolosi miliare deUa faringe. Definition. — Ulcerations and deposits of milianj tubercle arising in the -pharynx either as primary local manifestations of constitutional phthisis or secondary to similar phenomena occurring in the lungs, larynx, or other organs of the body. History. — Within the last fifteen years there has been a growing tendency to recognize certain conditions of the pharynx accompanied by idceration as intimately connected with the tul3ercular diathesis, and to differentiate the obscure phenomena sometimes met with in other affections especially syphilis. The subject of pharyngeal phthisis had been touched on by Green,i Bryk,2 Eindfleisch,^ Wendt * and Long Fox,5 &c. ■ but the symptoms and pathology of the disease were first accurately described by Isambert « and subsequently so thoroughly elucidated by Frankel,7 that but little remains to be added to our clinical knowled^re of the malady. ° Etiology. — The etiology of tubercular disease of the pharynx is the same as that of phthisis palmonalis, viz heredity or depression of the vital powers residting most frequently from breathing impure air, or from insufficient nutriment, or residence in a cold, damp climate. The data 1864 '^^'*°^^'^'^^ Treatise on Pulmonary Tuberculosis." New York, I ''Wien Med. Wocbensch." 1864, xiv. Nos. 42, 44 ■ Lehrbiich d path. Gewebelehre." Leipzig, 1869, p. 310 * "Archiv. d. Heilkimde," xi. p. 666 ^ « "Annal. des. Mai. de I'Oreille, et du Larynx," t. ii. p 169 " London Med. Eecord." January 15 and Febi-uarv 15 1877 and "Berl. Kl, Woch." Nov. 1876. ^i-oiuaiy 15, 1877, 96 DISEASES OF THE THROAT AND NOSE. furnished hv the cases observed up to this time do not, however, satisfactorUy explain why the pharynx should in certain instances, become the site of tubercidosis Almost al of the patients were sinudtaneously affected with pulmona.y Dhthisis, but by their own statements their attention had hrst been arrested by a progressively increasing soreness of he throat In one case, however, reported by Isambert,^ the subiect bein<^ a female chUd, ^t. 4^ no pulmonary symp- tomf couM °be detected, although the condition of the rrynx was typical of tubercular disease Erankel, as a result of his own observations, remarks that the patients seen by him " had not previously suffered from chronic affectioL of the pharynx, and no ground can be found for assuming that, in them, the pharynx was a locus mmoris r See There was no hyperplasia of the tonsds, nor any conSn of the pharynx or fauces, which woidd en itle me to assume that a cheesy deposit was present here. He, t Worrproposes to leave the question of etiology open for ^'^^^^^ms.-V^^i^^i^ suffering from pharyngeal phthisis exldb the same succession of symptoms as those whjch a^characteristic of ordinary consumption-the throat atfec- W behiT probably only an accidental complication. The un.s f no at U diseased, soon become affected ; cough, eSoration, anorexia, hectic, and progressive debihty super- vTe and finally, death ensues from exhaustion. Subjec- tivelV ?he most prominent symptom of pharyngeal phthisis the pain in the throat. The odynphagia is always great, 0 much so that Isambert concludes that the pam m deglu- ''"'\ T,}^elocT^^^^ i^^^ contributes much towards ment of the J^?^^ ^-^^^ 'g^^ere stabbing pain m the ear hastening a J^f^^^^^^^^^^ complained of. According during degluti ion^^^^^^^^^ tlberclsis of the pharjoix, f tP^nSCtlrculosis characterized by variable evening of acnte miiiaiy tuoe ^^^^ ^.^^^^^ ^^^^ temperatures, otten up uu xv 1 Loc. cit. p. 168. ^-Loc.cit.Jan.l5,p.2. ^ Loc. oit. PHTHISIS OF THE PHARYNX. 97 instances as high as 107-06° Fahr. In one of Fninkel's cases, the curve of temiDerature resembled at first that seen in typhus, and afterwards that of hectic. In another, the tem- perature of continued fever (100-4° Fahr. to 101-2° Fahr.) was sustained, Avhen it rose suddenly to 107-06° Fahr., and at the patient's death the thermometer registered 103-1° Fahr. Objectively, the appearances presented by tubercular lesions of the pharynx are highly characteristic. The ulcers generally begin on the lateral walls of the pharynx, and spread thence to the roof of the mouth, and the posterior Avail, as well as to the velum palati. They are of a lenticular shape, and according to 0. Weberi bear a great resemblance to the corresponding intestinal affection. He describes them as possessing "a caseous, broken-down floor, with undermined hypertemic edges, in which new tuberculous deposits are imbedded in various stages of development. These rapicUy disintegrate, and cause necrosis of the mucous membrane lying between them." In the neighbourhood of the rdcers, grev nodules of the size of millet seeds often spring up, and ultimatelv break down so as to form fresh ulcerations. According to Franliel a disposition to hypertrophy co-exists with the destruction ot tissue; and in the vicinity of the tonsils, especiallv, polypoid excrescences often arise from the ulcerated base it the uvida become affected it may be enlarged to the thickness of the thumb. Tumefaction, when present is as Isambert remarks, not due to an ordinary edematous condition, but to an infiltration of the tissues by a kind of gelatinous matter, which shows no tendency to escai^e when scarification is practised. The tendency of the affection lowever, is to cause wasting of those parts which do not become the actual seat of the morbid deposit, and in some cases, the uvula is seen to be atrophied instead of being enlarged. When ulceration attacks the epi- giottLs^ the process of destruction often reduces that or-an in a short time to a mere stump. The disease in most ci;:ses spreads to the upper part of the larynx, but as a rule does not extend further down than the ventricular bands, and does not give rise to caries of the cartilages. It is worthy of note tliat the post-mortem examination of the cases of pharvn^real phthisis hitherto met with, has not revealed any\ubSar deposit, or ulceration of the c^sophagus. In nearly every p.'seo^""^^-'^-'^^"''"- ^P^"- Chir.Pithau.Bmroth,-' Bd. iii. H 98 DISEASES OF THE THROAT AND NOSE. case of tuberculosis of the pharynx, there is eiilargenieiit of the cervical glands which, in many instances, attain the size of a walnut. The following cases i serve to illustrate the disease : — "Mrs. M. C, a inamed woman, set. 29, came under my care on January 14th, 1877. Her family liistoiy was bad, her mother and only brother having died of consumption. She had always been deUcate, but had two healthy childi'en, and there was not a trace ot syphilis in the mother, or either of the children. In October 18/0, she first experienced pain in swaUowing, and in the November f oUovsang the glands on both sides of the neck became sUghtly enlarged. &mce October she had suffered very much from feverishness, especiaUy at nio-ht, when she always became very thirsty. On examination she was found to be much emaciated, and there was evidence ot softening of the apex of the left lung. On examining the thi-pat, smaU ulcers were seen covering the palate and the right posterior piUar of the fauces, whilst the whole of the back wall of the pharynx was studded with smaU idcers, varying in size from a pm s-head to a split pea. The uvula was an iach in length ; on the right side of the neck one gland was as large as a pigeon's egg, and there were two other indui-ated glands, each about the size of a filbert nut. ihe epio-lottis was of a pale colour, and much thickened, and presented a turban-Uke appearance. There were supei-ficial ulcers occupying its rio-ht half. The arv- epiglottic fold was swoUen, and presented a pyi-iform appearance. The right ventricular band was also thickened and ulcerated. The vocal cords were sHghtly thickened, and the vocal processes of both cords idcerated. The patient remained under my care for thi-ee weeks, and diu-ing this time no marked change took place in the appearances described ; three small ulcers however formed at the back of the tongue, and the anterior piUar (of the fauces) on the right side became ulcerated. The patient was treated ^ylth^ soothing mhalations (vapor benzoiui and vapor conii : Thi-oat Hospital Phai-maoopoeia), but they faUed to relieve pain, which was yeiy ma™ She subsequently obtained gi-eat relief from the msufflation of moruhia, but I heard that she died early m March. "X No;;mber, 1876, a yoimg lady, ^t. 15, accoimt of oreat diflculty in swaUowing. Her father had been imdei m^ care sLe years previously for lai-yugeal phthisis, from which h J had ultimately died; the rest of the family were healthy^ This patient had enjoyed good health tmtd pre^ous Ji^^^^^^^ she was accidentaUy immersed m a river, '/^^^^^'^here voice On examination she was f oimd to be very thin and weak , tnere wTmai-ked duhiess at the apices of both hmgs, but no e^^dence of XSn^ ThTwhole of the phaiynx was found to be studded with £r°vdcerations, which, however, were -^^^ °^tfe%C"- terior wall. The uvula was greatly thickened, but ^eiy httle eion S^'loS S oa o^e o«oS 106? The palie.t .te reu^n^S ' SeealBoDr.G.e'.0Me»: " Baitli. Hosp. Eeporte," vols. ™. and is. PHTHISIS OF THE PHARVIs-X. 99 xmder my care for thi-ee 'weeka, and deriving considerable relief from iusiiiflatiou of moi-phia twice a day, left England to pass the ^vinter at Cannes, but took cold in Paris, and died in a few days." Pathology. — At tlie necropsy of a ease, reported by Friiukel,! ulcers were found on the lateral walls of the pharynx, on the roof of the mouth, on the nasal por- tion of the posterior wall of the pharynx, and on the velum, while they ceased abruptly at the commencement of the oesophagus. On microscopic examination the base of the ulcer is found to be occupied by a thick infiltration of round cells, wliich extend deeply into the sub-mucous tissue, even as far as the muscles, which, at these parts, present the transverse strife less distinctly than usual. The round cells infiltrate the connective tissue of the glandulte, but do not invade the special gland cells, which are generally in a state of fatty degeneration. The latter have a great tendency to become cheesy, and portions of cheesy matter often lie among the round cells. Isolated grey nodules are rare. In Franlcel's case, above referred to, both lungs exhibited cheesy broncho- pneumonia, and an abundance of grey nodules ; in the left lung there was a cavity as large as a hen's egg. There were also tubercles in the pleura, liver, and spleen, and tuberculous ulcers in the intestines. In other cases miliary tubercle was found in the choroid membrane and in the liidneys, prostate, thyroid body, &c. Z)/rtryMos/.s.— Tubercvdosis of the pharynx appears to have been generally confounded with syphilis, and to this fact the comparatively scanty amount of clinical observations is probably due. I can recall many cases which, in former years, I pat down as tuberculo-syphilitic disease, but which I have no doubt now were instances of pharyngeal phthisis. J^ow that the disease has been so carefully described, it wiU be seen that there are many points of difterence between the two maladies; and the observant practitioner, when once_ warned, will not be Idvely to make an error in dia- gnosis. The lenticular ulcers of pharyngeal phthisis, Avith the development of grey nodules in their neighbourhood are extremely characteristic, and when once seen can always afterwards be readily recognized. The history of the indi- vidual cases wiU usuaUy afford considerable aid to diagnosis Imt It must not be forgotten that syphilis and tuberculosis niay, in some instances, co-exist. Should tubercle of the choroid be present, as occurred in one of Frankel's cases, we ' Loc. cit. p. 1. 100 DISEASES OP THE THROAT AXD NOSE. are justified in assuming that there is general miliary tuber- culosis. The fact that, in most cases, the pharyngeal symptoms first attract the patient's attention, is of positi\-e value in arriving at a diagnosis. Pro(7v^o^Y■6^— Tuberculosis, when manifesting itself in the pharynx runs a more rapid course than ordinary pulmonary phthisis. Thus, in all the recorded cases, death occurred in a period varying from two to six months. In none of the cases has recovery taken place, and it is probable that the pharyngeal lesions indicate such an extensive implication of all the structures of the body with tuberculosis, that the issue must necessarily be fatal. It is, however, unquestionable, that death ensues more rapidly in some cases than in others ; and, for this reason, Cornili ^nd Isambert^ have come to the conclusion that there are two varieties of pharyngeal tuber- culosis, viz., an acute, and a chronic, form. As the disease almost always terminates fatally in six montlis, this distinc- tion is scarcely well founded. A certain modihcation in our prognosis as to the duration of disease may, however, be required in different cases. Treaiment.— As Frankel^ observes, the recognition of tuberculosis of the pharynx is more creditable to our dia- gnostic acumen than to our therapeutic skiU. Eut small results can be hoped for from either local or constitutional measures in such cases. The administration of cod-liver oil with a general tonic and analeptic treatment may be attended with some slight benefit, and the life of the patient may be prolonged for a short time. Almost all writers agree in discountenancing the application of astringent or caustic solutions to the lacerated 'surfaces. Isambert states that he has found some advantage from the local use of glycerole of morphia. When the pain is great sedative remedies may indeed be employed as palliatives, especially in order to lessen the difficulty of swaUowiug. With this view insuffla- tions of acetate of morphia, gr. } to gT. ^ once or twice daily, mixed with powdered starch, and iiot soothing inhalations, can often be used with decided benefit ; whilst in thv worst cases recourse must also be had to nutritive enemata. 1 " Journal des Connaissances Medicales," July, 1875, p. 193. 3 Loo. cit. p. 1G4. Loc. cit. p. 48. TRAUMATIC PHARYNGITIS. 101 . TRAUMATIC PHARYNGITIS. Latin Eq. — Pharyngitis traumatica. French ii'g.— Pharyngite traumatique. German i,'^.— Trauraatische ScliluudentzUndung. Italian iJf/.— Faringite traumatica. Dbpinitiost.— ylcMiJe, often mdomatous, wflammation of the phari/nx, caused hi/ swallowing boiling water or camtic sub-stances, inhalation of flame, ^ i Floury at Schupfe : " Nouveau Diet, de Med. et de Clur. vol. i. p. 297. ^ "Medical Gazette," 1842-13, p. 694. POEEIGN BODIES IN THE PHARYNX. 109 (three inches long) ^Yas found fixed transversely cacross the pharynx, the Avall of Avhicli it had perforated opposite the middle of the thyroid cartilage, whilst the point was lyino- in the common carotid artery. The larynx, trachea, andltomach were found filled with clotted IdIoocI. A some- what similar case is related by Fingerhuth,i ^hich a piece of the stem of a long tohacco pipe became lodged m the side of the pharynx, and after an interval of eight months occa- sioned fatal hfemorrhage by wounding the carotid m a sudden movement of tlie head. In some cases swallowing becomes so painful that deglutition is rendered almost impossible. When a large foreign body is impacted in the pharynx, the chief danger arises from the probability of suflfocation on account of the entrance to the larynx being obstructed. In rare instances the foreign body may become impacted _ m such a way as to press down the epiglottis and occasion sudden death. In such a case the patient appears to die in a fit of apoplexy. If a patient complain of a foreign substance being arrested in the pharynx, a view of the parts can sometimes be obtained by placing the individual with his mouth ojDen opposite a window, directing him to take a forcible in- spiration, and pressing down the tongue with the finger. In most cases, however, the laryngoscope must be_ made use of, as by this appliance alone is it possible to inspect the Avhole of the pharyngeal cavity. When the parts are thoroughly examined in tliis way, it is rare that a foreign body, however small, escapes notice ; but when nothing can be seen, further examination should be made with the finger, as it is possible that a small, pointed, semi-trans- parent body, such as a fish-bone or bristle, may in this manner be detected. Even coins have been discovered imbedded in the folds of mucous membrane which pass from the sides of the pharynx to the larynx, after haying remained undetected for a considerable time in this position.^ Thus a case is recorded in which a halfpenny remained in the pharynx of a child eight months, and was ultimately brought up by a fit of coughing.'' In rare instances foreign bodies may get into the pharynx by penetrating the structure of the neck. In illustration of this fact an instance is on record in which a surgeon removed from the pharynx of a 1 Preuss. " Vereinszeitung," N. F. vii. No. 23, 1864. 2 Durham: "Holmes' System of Surgery," vol. ii. p. .519. ^ Osner Ward : " Trans. Path. Soc." 1848-49. 110 DISEASES OF THE THROAT AND NOSE. ■woman a sewing needle, ■which had been thrust into her neck half an hour previously. ^ Diagnosis. — The history of the case, and inspection of the pharynx, will generally afford conclusive evidence as to the nature and position of the foreign iDody. It must be remembered, however, that the substance may some- times have been swallowed or ejected a short time after its lodgment, though the patient may still continue to ex- perience a sensation as if something were sticking in liis throat. When the pharynx is nmisually sensitive, or especially when a particular spot on its walls is in an irri- table condition, a patient after taking food is very likely to imagine that something has become fixed in the throat. Hysterical women are particularly prone to become possessed with such an idea, and to persist in it for Aveeks or months in spite of all assurances as to the groundlessness of their delusion. Again, with respect to children, serious symptoms, due to the impaction of a foreign body in the throat, may be present, whilst the history of the case does not afford the slightest clue to the origin of the phenomena. Prognosis. — If the foreign body can be removed, the prospect is of course perfectly satisfactory, but if it re- main in the throat, the prognosis must depend on its size and nature. Thus a large body may threaten death from suffocation, and a small one may give rise to a fatal result by penetrating a vital part. A sharp body, such as a bone, is more dangerous in its remote consequences than a smooth one. Eokitansky^ thinks that the impaction of small hard bodies, such as cherry stones, at the lower part of the pharynx may cause the formation of a diverticulum. Treatment. — ^The pharynx being as thoroughly accessible to instruments as it is to vision, foreign bodies, lodged in its cavity, can generally be easily removed. Large pieces of soft substances, such as lumps of meat, may be seized with the fingers or with forceps and extracted, or they may be pushed down into the gullet with a probang. Coins can be removed vyith forceps, or if they are impacted at the orifice of the oesophagus the money-probang may often be used with success. Small pointed bodies, such as fish-bones, bristles, pins, &c., imbedded in the substance of the tonsils, or entangled in the folds of mucous membrane, are best seized by suitable forceps, and drawn out in the direction 1 Jardine Murray: "Med. Times and Gazette," 18.j9, p. 468. - " Pathological Anatomy" (New Syd. See. Ti-aus.), vol. ii. p. 12. FOREIGN BODIES IN THE PHARYNX. Ill of their long axis. Plates of artificial teetli can usually be most easily extracted by the aid of forceps. When .summoned to a patient Avho is almost suffocated, it may not be possible to make a thorough exploration of the throat, and tracheotomy may be immediately necessary. The com- mon, but fatal, practice is at once to use a probang, and to force the obstructing object onwards. A foreign body, comparatively harmless in the pharynx, is thus often driven into the larynx or even into the bronchi, or may become impacted in the 02sophagus.i At the same time, great injury is often done to the soft parts. If the patient's respiration could support a probang, an inspection could certainly be made, but if he appear to be dying of apnoea, trache- otomy may be necessary before the extraction of the foreign body can be accomplished. When no foreign substances can be detected after careful examination, it is advisable, even though the patient's sensations lead him to believe that the cause of his trouble is not removed, to wait for some little time before subjecting him to further manipulation. For the sensations of the patient are often unreliable, and although the foreign substance may have been extracted, a feeling of heat, pricking, or constric- tion in the pharynx, may be experienced for some time afterwards. Such sensations deceiA^e the sufferer by simidating the presence of some offending substance. By leaving the parts at rest, if there be any foreign body in the pharynx, it wlU often work its way out, and be swallowed or ejected by the mouth, or it can be subsequently removed. As a rule, the sensations which remain after the extraction of a foreign body, generally subside in a few hours, although in some cases they persist for several months, and cause the utmost misery. There is usually some hyperaemia, and pro- bably also a morbid condition of the terminal nerve fibres. Such cases are freqxiently difficult to ciu'e. The application, however, of astringents to the mucous membrane, and the employment of galvanism, usually relieve the symptoms after a time. In some instances change of air and scene is neces- sary, in order to disj)el the impression, and travelling should be recommended. In ordinary cases the discomfort remain- ing after the removal of a foreign body from the pharynx, wUl be much alleviated by directing the patient to sip a little iced water from time to time, or to suck and swallow ' Schrbtter: " Medical Examiner," March. 23, 1876. 112 DISEASES OP THE THROAT AND NOSE. sinaU pieces of ice. It must not be forgotten that occasian- ally two foreign bodies— especially fish-bones— may be pre- sent at the same time in the pharynx without the. patient being aware that there is more than one substance. Hence, if the sensations remain after the removal of the foreign body, a further examination should be made. A remark- able instance of this occurred to me a few years ago. An eminent Glasgow surgeon consulted me on account of a fish- bone which had become lodged in his throat three or four months previously. I succeeded in removing a fish-bone from the lower part of the pharynx. I told him that " he might feel the sensation for a day or two, but that there could be nothing more in the throat." Two days after- wards the gentleman returned to me, saying that he felt sure there Avas another bone near the site of the one I had removed, and on making examination I found that his sensa- tions Avere accurate, and that a second bone was lodged in the throat at the spot indicated. On its removal, no further unpleasant feelings were experienced. It may be remarked that, between the removal of the first and second bone, the patient had not partaken of any fish. NEUEOSES OF THE PHAEYNX. Latin Eq. — Neuroses pharyngis. French Eq. — Nevroses du pharynx. German Eq. — Neurosen des Schlundes. Italian Eq. — Nevrosi deUa faringe. Definition.— DisorcZeref? sensihility of the mucous mem- brane of the ijharijnx, or a perverted or impaired action of the 2)haryngeal muscles, due to central or local disease of the nervous system. Nervous affections of the pharynx are divided into neuroses of sensation and neuroses of motion. Neuroses op Sensation. Under tliis head four conditions of the mucous mem- brane in which the sensibility is altered may be grouped, viz., auLBsthesia, hyper^esthesia, parixjsthesia, and neuralgia. Amesthesia.—T\-iis neurosis is generaUy of _ little clinical importance, but occasionaUy, according to Krishaber,^ dimi- 1 " Gazette Hebd," 1872, p. 772. NEUROSES OF THE PHARYNX. 113 nished sensibility is one of tlie earliest symptoms of jaro- gressive bulbar paralysis. It is nearly always present in dipbtheritic paralysis. In insane patients ^ it may occasion- ally, bowever, be found to exist mtbout any motor dis- turbances, or may result from tbe action of certain drugs, sucb as morpbia or cbloroform applied locally. To cure tbe affection, galvanism may be applied to tbe part, and strycbnine administered internally or introduced bypoder- micaUy. Hijpercesthesia. — Abnormal sensibility is of much more frequent occurrence tban tbe affection just described. It is met -with very frequently in individuals otberwise perfectly healtby, and often forms one of tbe greatest difficulties tbe laryngoscopist bas to contend witb in order to obtain a view of the interior of tbe larynx. Tbe introduction of the Eus- tachian catheter may also be rendered impossible on account of byperaesthesia in tbe pharyngo-nasal region. It may be useful to mention here that even in the normal condition there is a considerable difference in the sensibility of various parts of the pharynx. Thus it is greatest on the arch of the palate, whilst the posterior -wall of the cavity may generally be touched witbout provoking any reflex action. Every variety of hypertesthesia may be met with in hys- terical women,- whilst an increased sensitiveness of the parts generally accompanies inflammatory conditions, acute or chronic. No special measures are demanded for the cure of bypersestbesia of the pharynx, except when the practitioner requires to pass instruments into the cavity for the examination or local treatment of the adjacent parts. These will be described in tbe article on " Laryngoscopy." Parcestliesia. — This condition may occiu- without any overt cause in hysterical women, but it generally follows the removal of a foreign body. The patient complains of something sticking in the throat, such as a hair, a fish- bone, or a rough fragment of some hard substance. When this morbid sensation is consequent on the previous lodg- ment of a foreign body it generally passes away spontane- ously in a day or two ; but sometimes, it may remain for montbs — or even years, as already explained mader " Foreign Bodies in the Pharynx." When dependent on hysteria, the general measures usually adopted for the relief of the complaint should be employed. ^ Ziemssen's " Cyclopaedia," vol. vi. p. 993. I 114 DISEASES OF THE THROAT AND KOBE, neuralgia.— This affection of the pharynx has not hitherto been accurately described. Tiirck,! however, mentions some half-dozen examples (four occurring in females) where severe pains of the soft palate, principally on one side, were com- plained of. The affection appears to have been incurable m one instance, whilst the rest recovered in a few weeks under the influence of strong applications of nitrate of silver. Some of these cases, however, approached more nearly to simple hypertesthesia or pareesthesia than to veritable neuralgia. Many instances of this disease have come under my notice. In most of the cases the patients were young girls under twenty, but I have met with the affection m married women betweek thirty and forty. In some of these cases there was anm, and more rarely chlorosis, but many of the patients were otherwise healthy. In most of the cases the pat ents were not in the least hysterical. Sometimes there was local hyperemia : sometimes ansemia. In' the former cases free scarification proved very useful. In nearly aU instances applications of tincture of aconite, three or four times a day were of the greatest benefit, and this drug has often proved, in my hands, the only remedy which gave rebel. Neuroses of Motion. Sms7n.— This symptom is rarely met with except in cases of acute (Bdema of the uvula, intense pharyngitis, and hydrophobia. The constrictors of the pharynx however, often participate more or less in spasmodic stricture of the oesophacTUs. Twitching movements of the palate, accord- inc. to Vacmer,2 also occur in advanced cases oi ixiralysi>< nnifans Thus, in a patient suffering from constitutional ZhnS and paralysis of one haK of the body (the pa ate not beino- involved) Wagner observed movements, synchronous with the pulse, on one side of the palate. Prnrdvsis —There are four kinds of paralysis of the palate and pharynx :-(l) the affection, which is a frequent sequel ordrphtCia, Ld occasionally met .vith after common ZaSl (2) the sHght paralysis which is sometimes asso- S Uh facial paralysis 5 (3) the loss of power, which is one of Jhe most marked phenomena of progi:essive bulbar Olio ui _ paralysis of the constrictors of the il Iiw"b Lsociated with a sunilar conditio,, of the oesophageal canal. 1 "Wiener Allgem. Med. Zeitung," No. 9, 1862. 2 Ziemssen's " Cyclopfedia," p. 993. NEUROSES OP MOTION. 115 Diphtliaritio paralysis of the. palate is a common sequel of membranous sore throat. An analogous affection, Kow- ever, sometimes follows a simple angina, and may perhaps arise from mere dehility. Cases of the former kind have been reported by Drs. Gubler,i Broadbent,^ Hermann Weber, Silver, and others; and Dr. Broadbent^ has recorded an instance in which the disease (associated with loss of power of the adductors of the vocal cords and slight dysphagia) arose spontaneously in a child six years of age. It is pro- bable that inflammatory disease of the pharynx, such as tonsillitis, general pharyngitis, putrid sore throat, or syphilis, may give rise to more or less disturbance of the motor apparatus of this region ; but it is only in diphtheria that other nerve centres suffer, so that this fact affords a means of differential diagnosis. The voice acquires a characteristic nasal timbre, the modification of certain articulate sounds being very characteristic, owing to the impossibility of closing the naso-pharyngeal passage. Thus ruh, head, and egg become rum, hent, and enZi;.* On inspection, the velum pendulum palati and uvula are seen to be relaxed, and although during inspiration and expiration the uvula moves backwards and forwards under the force of the current of air, the power of voluntary raising it is, to a great extent, lost. This feature is generally uni- lateral, and when bilateral it always affects one side much less than the other, giving rise to a mere paresis of the muscles on the side least affected. There is also generally loss of sensibihty in the veil of the palate. The affection usually comes on about a fortnight after the commencement of con- valescence, and is sometimes followed by general paralysis or paresis of the muscles of the extremities. The patient first perceives the difficulty of swallowing, in taking fluids, which frequently regurgitate through the nose or pass into the larynx. This symptom is partly due to the implication of the depressors of the epiglottis. The power of expectoration is often lost, and mucus accumulates about the lower part of the pharynx, and is only dislodged by an effort of vomiting. The taste is always more or less blunted. In some cases a con- stant pricldng sensation is felt in the throat. Some illustrative cases will be found under "JS^euroses of the Larynx," and the ' Log. cit. ^ " Lancet," March 4th, 1871. ' " Clin. Soc. Trans." 1871, p. 92. * Bonders: " New Sydenham Soc. Trans." 1864. 116 DISEASES OF THE THROAT AND NOSE. vaxious associated paralyses which occur_ in diphtheria are hrieflv described in the article on that subject Galvanism and faradism should be ^If li'^^ two by means of the laryngeal electrode until a decided ireiion of the symptoLls obtained.. At f e samej^ie general tonics are indicated, and strychnia may ^« ^^imni " tered, either hypodermically or by the mouth. The patie t should only be aUowed to swaUow panada, soups made aLst solid by the addition of corn flour, and very town jellies. Occasionally it may be necessary to feed mth the oesophageal tube, or per rectum, ,,nrahisis Paralysis of the palate in association mtli facial paralysis o<^:^iJ^ to Erb,i ten the cause ^f^^^^^^^^^^^^ situated above the geniculate ganglion. The uvida usi^^^^^ deviates to one side or the other-generaUy to ^^^^^^^J side and scarcely moves m phonation. This neive-iesion does not require' any special treatnjent, as - unimportant though interesting phenomenon sometmies occurrin<^ in connection with facial paralysis. Palatlglosso plumjncjeal paralyds is always one of th^^ most marked phenomena of progressive bulbar Paialy^is^ Sie disease is kid to be rarely , ^^^r^J^' f ' 0 40, but I have treated patients aged 27, 29, and Expo sure to cold is often the cause of the disease, but it has been Xwise attributed to prolonged mental exc— ^^^^ fitiiflr/no6i^.-Separate spots of aphthae are not lilcely to be ruistaken, but when the disease is confluent the appearance of a false membrane is simulated, and close examination wiU be necessarv in order to diagnose between this malady and Lhtheria. The wHtish pultaceous matter which breaks up on being touched can be easily distinguished from the homogeneous, closely adherent, and tough Biembmne of weU marked diphtheria, but there ^^^o dXrenttt occupv a middle ground and are very difficult to difleientiate. SoZoX-The nature of the affection has to a great extent been explat^ed in speaking of the symptoms. It remains oXto be added th^t a special fungus, the onUum a b^can is often met with in great quantities m the Avhitish coid- lilce matter which characterizes the disease. 1 "Diet, des diet, de Med." DIPHTHERIA. 119 Prognods. — In infants aphthis seldom cause death, but in rare cases the oesophagus may become ulcerated to such an extent as either to render swallowing impossible or to pro- voke ejection of food as soon as it reaches the stomach. In the last stage of debilitating diseases aphthse generally constitute an immistakable sign of approaching dissolution. Treatment. — In the case of infants it is very important to attend to the diet, which, if possible, should consist of the mother's miUt alone. Lime water, or the alkaline carbonates, are often of great service. As an internal agent chlorate of potash appears to exert a remarkable influence in hastening the disappearance of the aphtha. Five or six grains may be given every four hours. Pernitrate of iron may also be iised advantageously as an internal remedy. A general tonic and analeptic treatment will always be required in addition to other measures. The Mel Boracis, P.B., or borax diluted with white sugar (1 in 10), is an excellent remedy in the case of children. A pinch of the latter mixture should bo placed at the back of the child's tongue, and allowed to dissolve. The pain and soreness are usually much relieved by the frequent use of honey or glycerine, with borax. Equal parts of glycerine and turpentine are very beneficial in the later stages. The ulcers can often also be successfully treated by daily application of sidphate of copper (gr. x. ad 3j.). In the case of adults where there is great soreness, free cauterization with the solid stick of nitrate of silver affords immediate and marked relief. Sir William Jenner ^ first pointed out that in cases where a parasitic fungus is pre- sent a lotion of sulphite of soda (a drachm to the ounce) will kiU the parasite, and thus cure the disease in about twenty four hours. DIPHTHEEIA.2 Synonyms. — Several pages might be written of synonyms which at different times have been employed in describing diphtheritic affections, but simple inflammatory diseases, 1 "Med. Times and Gaz." vol. vii. p. 183. ^ Inasmuch as a diphtheria generally commences in the pharynx, and when it affects other parts, most frequently attacks them by extension, I have thought it right to treat the whole disease in this Hection. I am the more inclined to adopt this jslan as I entertain the view that croup is only a form of diphtheria in which the local expression is found in the larynx and trachea— as it often is in the nares (with or without its occuiTence in other parts). Tliis proposi- 120 DISEASES OF THE THROAT AND NOSE. distinctly pellicular affections, and lesions of innervation have been so confused together by the earlier writers in medicine, that there is little or no advantage to be gained by collecting the numerous synonyms employed by different authors at various times. The term diphtheriiix was originally suggested by Bretonneau, Avho, observmg tlmt the disease was differentiated from other similar maladies by the formation of a false skin or membrane, coined the word dvphtherite from the Greek dccj^eepa, a skin or parchment, and ite from 'Irrjs (d,..), hasty, impetuous, the well-known termi- nation used in medicine to imply inflammation. Trousseau subsequently modified the word to diphtherie, m order to get rid of the etiological doctrine of inflammation which the af&x indicated, and the term diphtheria was adopted by our Eegis- trar-General. Names indicative of inflammation stdl hold their ground, however, amongst German and ItaUan writers. Latin Eq. — Cynanche membranacea ; C. maligna; G. pharyngea- maligna ; C. pharyngea epidemica ; C. tracheahs. Angina suffocativa ; A. polyposa ; A. membranacea ; A. per- niciosa. Diphtheria. Diphtheritis. French ^g.— Angine couenneuse; A. fibnneuse. DipJitne- rite. Diphtherie. -,131 German ^3.— Diphtheritische Entziindung der l.aclien- und Kehlkopfsschleimhaut. Italian. JJg.— Mala in canna. Difterite. Definition —yl specific communicaUe disease, occurring epidemically, endemically, and solitarily,^ and characterized L more or less inflammation of the mucous membrane 0/ the pharynx, larynx, or avr-passarjes, and hy the formation on the surface of those parts -especially on the mucous mem- brane of the fauces and loindpipe—of a layer or layers of himvh or false membrane, genercdly shoioing signs of bactiroid mycosis. During an epidemic other mucous surfaces exposed to the air, and wounded surjace. of the common integument occasionally, but less frequently, become Tip rlPVPloBed in the body of the article in some detaH, and I influence. DCPHTHERIA. 121 cov&)-ed with a layer of hjmpli, stihsequently to, or indepen- dently of, a formation of membrane in the more ordinary situations. The disease is generally of an adynamic character, is often associated loith a disturbance of the renal function (albuminuria), and is frequently followed by lesions of innervation rarely giving rise to permanent paralysis. The symptoms as regards respiration, vocalization, and deglutition vary toith the site of the disease. By far the larger p>rop)ortion of fatal cases terminate by gradual apncea, but a certain percentage sink from asthenia, blood-poisoning, and cardiac thrombosis. History. — The presence of a membraniform deposit in the fauces seems to have been regarded as a morbid condition, attended with considerable danger to life, from the earliest times. Hippocrates is supposed to have called attention to it more than two thousand years ago, and Aretteus has given a description which answers ia many respects to the disease as now seen. But centimes before the time of Hippocrates an Indian writer had included ia his |' Systera of Medicine " ' a description which is even more suggestive of diph- theria. The writer mentions a disease ia which "an increase of phlegm and blood causes a swelling ia the throat, characterized by pantiag and paia, destroying the vital organs, and incurable." ^ He also says, " a large swelling in the throat, inipeding food and drink, and marked by violent feverish symptoms, obstructing the passage of the breath, arisiag from phlegm combined with blood, is called ' closing of the throat.' " ^ With these passages it may be well to contrast the description given by Aretseus of the Syriac ulcer, a malady which is generally considered to have more poiats of resemblance to the diphtheria of to-day than any other disease of antiquity. Describing ulcers on the tonsils,'' Areteeus teUs us that some are mild and harmless, while others are pestilential and fatal. The former — which are common — are clean, small, and supei-ficial, and are unaccompanied either by pain or inflammation. The latter — which are rare — are extensive, deep, putrid, and covered with white, Uvid, or blackish concretion. Aretaeus then goes on to describe the way in which, ia fatal cases, the disease progresses, stating that "if it extends rapidly to the chest through the windpipe, the patient dies on the same day by suffocation." No more definite description of any disease which we can identify with diphtheria has been given, either by the contemporaries or the successors of Aretseus, and we must pass over many centuries before we come upon any authentic record of the prevalence of such a disease. 1 This systematic work on medicine is written in Sanskrit, by D'hanvantare, and compiled by his pupil, Susruta. A Latin translation, by F. Hessler, was published at Erlangen in 1844, and is in the British Museum ; it has the following title : " Susrutas Ayurvedas ; id est Medicinee Systema a Venerabili D'hanvantare Demonstratum a a. Discipulo Compositum." It is from this translation that the quotations in the text are taken. 2 Ibid. p. 202. ^ Ibid. p. 205. The following passage may also possibly describe diphtheria : — " 8i quin valde lugens semper suspirat, interruptam vocem, et aridum solutum- que sonimi habet in respirationis viis, pMegmate oblitis, hie morbus propter sus- pirium vocis occisor oognoscendus est." — Ibid. 20S. Areteeus: " De Causis et Signis Acutoruni Morborum," lib. i. cap. 9. 122 DISEASES OF THE THROAT AND NOSE. It is not until we anive at comparatively modem times that we find diphtheria forcing itself upon the attention of xAysicians as a distinct disease. BaUlou, a distinguished French physician, who flourished in the last quarter of the sixteenth century, was the first to publish an accurate description. It is in his writings that we find the first definite mention of a false membrane.^ A few years later, the same appearance was noted by several Spanish physicians as occurring in the course of an epidemic disease, which they minutely portrayed imder the name of " garrotillo." The best description is that of Villa Real (1611), who states that he has seen a thousand times (miUies vidi) in patients, at the first onset oi the disease, a white matter in the fauces, gullet, and throat. He adds that this matter is of such nature that if you stretch it with youi- hands it appears elastic, and has properties like those of wet leather- facts which he noticed, not only by observing the matter coughed up by the living, but also by the examination of it ia the dead.^ The descriptions of Fontecha^ (1611) and Herrera * (1615) are less satis- factory, as containing no account of post-mortem appearances ; but they are valuable in so far as they confirm the fact of the prevalence of garrotillo in Spain between the years 1581 and 1611. Some years subsequently to the latter date diphtheria appears to have prevailed as a fatal epidemic in Naples and other parts of Italy. Sgambatus » tells us that in 1617 a higlily contagious affection of the throat appeared, attacking the childi-en of rich and poor alike, and often sweeping away whole families. The same epidemic is described by Nola'^ andCamevale,'' the latter of whom asserts that it was identical with that which had been prevailing in Spain, under the popular name of "garrotillo." The writings of CortesiusS (1625) rend.er it nearly certain that the same disease extended somewhat later to Sicily. A membrane in the throat, which could be readily torn away, is dis- tinctly described as being one of its symptoms. The works of Alaymus^ (1632) and of Aetius Cletius'" (1636) have also been quoted as affording corroboratoiy evidence of the prevalence of diphtheria m Italy and SicUy during the seventeenth century. Medical literature is then sUent on the subject for nearly a centuiy, but after that tune follows a rapid series of observations from different parts of Europe. In 1713 Dr. Patrick Blair," in a letter to Dr. Mead, described a I Gulielmi BaUouii : " Epidemiormn et Ephemeridum," Ubri ii.. Parisiis, 1640, p. 2017-" Pituita lenta contumas quse instar membranee cujusdam artense ''t!JSi1S^is°deVmaIleal:V'DeSignis, Causis, Essentia, Prognostico et Cura- tione Morbi Suflooantis." Compluti, 1611, p. 3d, et seq. , « s^^f/DSputationes MedictB," &c. opus Doetoris Fontecha. Coi^pluti, 1611. * "De Essentia, Causis, Notis, Prsesagio, Curatione et Pi-»eautione M^bi Suflo- pantis GarrotUlo Hispane AppeUati," auetore Dootore Herrera. Matriti, 1615 cantis UaiTotmo^i P^^^^.^ Affectu, NeapoU Steviente Opusoulum," auetore "^"^ De'lS'e'^co PhSone^Anginoso Grassante KeapoU," Franciscus Nola. ^T^f^l EnWemico Strangulatorio Affectu in NeapoUtam urbem Grassanti et per reSia Neap^ et SicilL Vagante," auctor Jo Baptista Caxnevale. Neapoli, Johannis Baptistaj Coi-tesn: " MisceUaneorum Medicinte Decades Denae." ^"Mard'i^tonu Alaymi: " Consultatio pro Uleeris Syriaci nunc Vagantis Cura- ''°^'^:ryl^^^i.'^!ul.tonor opus A.tii Cletti Si« B m i636. 11 •• Observations in the Practice of Physic," &o. London, 1.18. DIPHTHERIA. 123 disease as "the croops," which he says "was epidemic and universal" at Coupar Angus, and wHch was no doubt diphtheiia. In 1748 Ghisi ' observed an epidemic of the disease in Palenno ; in 1749 Marteau de GrandvUliers ^ described a similar outbreak in Paris • in 1760 the foi-mation of a membraniform concretion in the thi-oat is distinctly described by Dr. John Starr,^ as occurring in an epidemic in Cornwall, and in 1757 a sirmlar observation was made by WUcke * ia Sweden. In the same year Dr. Huxham ^ described an epidemic which had been prevalent at Plymouth, in which some of the Cases were examples of scarlatina anginosa, whilst others were undoubtedly cases of secondary diphtheria. „ -, ^ ^, At length the attention of the profession was fully caUed to the peculiar characters of diphtheria by Dr. Francis Home ^ of Edinburgh,^ who, in 1765, under the name of croup described an acute affection of the larynx and trachea, coming on insidiously, attended with the formation of a membrane in the pharynx and air passages, and often causing death by suffocation. Home appears to have been the fii-st to notice the quick, weak pulse which is so characteristic of the disease. The treatise of the Scotch physician attracted the attention of Dr. Michaelis'' of Gottingen, who, in an essay published in 1778, confirms and supplements his observations. From time to time epidemics of scarlatina were described in which the throat symptoms predominated, and some of these have been wrongly supposed to have been examples of diphtheria.^ The next record of the disease comes from America, where in 1789 Dr. Samuel Bard,^ of Philadelphia, published a minute account of "an uncommon and highly dangerous distemper" which had recently proved fatal to many children ia New York. Dr. Bard was a careful and pains- taking observer, and his monograph contributed very considerably to the accuracy of contemporary knowledge with regard to diphtheria. In 1798 another American j)hysician, Dr. John Ai-cher, published an interesting paper, and recommended a new remedy for the disease. In the year 1801 Dr. Cheyne,'' a British physician, published an essay in which he distinctly portrays diphtheria under the name of cynanche tracheaUs or croup. He recognizes it as the same disease as that referred to by BaiLlou, G-hisi, Home, and Michaelis, and gives a minute description and plates of the false membrane foimd in the trachea after death. In 1802 Dr. Cullen, i- the weU-known professor of the prac- 1 " Lettere Mediche del Dottore Martino Ghisi." Cremona, 1749. 2 " Dissertation Historique sur I'espC'ce de Mai de Gorge Gangreneux qui a resn^ parmi les Enfants I'annee demi&re." Paris, 1749. ■■' " Philosophical Transactions." 1752, vol. xlvi. p. 435. "Dissertatio Medica de Angina Infantum in Patria Eeoentioribvis annis Observata." WOcke, Upsalse, 1764. 5 " A Dissertation on the Malignant Ulcerous Sore Throat," 1757, thoueh generally quoted by -writers on diphtheria, is not referred to above, as it really deals with scarlatina anginosa. ^ " An Inquiry into the Nature, Cause, and Cure of Croup," by Francis Home, M.D. Edinburgh, 1765. " De Angina Polyposa sive Membranacei." Gottingen, 1778. 8 " An Account of the Sore Throat attended with Ulcers," by Dr. John Fothergill. London : Fifth Edition, 1769. " " Transactions of the American Philosophical Society." Philadelphia, 1789. 1" " An Inaugural Dissertation' on Cynanche Traohealis, commonly called Croup or Hives." Philadelphia, 179S. 11 " E.isays on the Diseases of Children, with Cases and Dissections," by John Cheyne, M.D. Edinburgh, 1801. 1802 '^ol*i'"™^219* ^'^^ Practice of Physio," by WiUiam CuUen, M.D. Edinburgh, 124 DISEASES OP THE THROAT AND NOSE. tice of physic in the University of Edinbm-gh, gave a description ■of cynanche trachealis, in which we cannot fail to recognize the diphtheria of modem times. For many years after its appearance Dr. Cullen's work was the favourite text-book on medicine with all British practitioners and students, and its author, therefore, may claim the credit of having rescued diphtheria from the region of discus- sion and monographs, and of ha-^dng given it a fixed and recognized position in medical science. The disease, however, was evidently still a rarity ia the British Isles, and it probably only occurred m the isolated form. In France the case was otherwise : the disease was well known as a frequent visitor, under the name of croup, and having caused the death of some of the members of the Imperial family in 1807, a prize was o£Eered by Napoleon I. for the best essay on the subject. This led to the publication of the valuable works of Albers, Jui-ine, and Eoyer-CoUard— works which were worthy pre- decessors of the classical memoii-s of Bretonneau.^ The latter owed their origin to an alarming outbreak of the disease at Tours in the latter part of the year 1818. The epidemic was most carefully investigated by Bretonneau, who published an account of his re- searches in 1826. An accurate description of " diphtherite " was given by Dr. Abercrombie in a work published in 1828.= The disease appears to have prevailed in an epidemic form in Edinburgh in the year 1826, but otherwise it was by no means a common affection in this country. In fact, after the brief notoriety conf en-ed on diphtheria by the works of Bretonneau, the disease seems to have passed from the mmds of Eno-Ush physicians, and its very existence to have been almost forgotten. It still occurred from time to time in all parts of Europe, but it did not excite attention to any great extent imtil the year 1853, when it broke out with some violence in Paris. In _18.5o an epidemic at Boulogne, which was especiaUy fatal to the resident English, excited considerable attention, and during the two foU^wmg years serious outbreaks were reported from different parts of France. The first case of the greatest epidemic of the disease which, as fM- as is known, has ever occurred in this country, was imported from Bou- loo-ne to Folkestone in 1856,3 ^ut it was not till 1868 that the disease attained very alarming proportions in this country. Spreadmg, as it seemed, from many independent centres, it raged as a wide -spread and fatal epidemic during 1859, and continued very seriously prevalent during the three foUowing years.* Since that time diphtheria has not appeared in England with anything like the same mahgnancy ; it stiU claims several thousand victims annuaUy, but its invasions ai-e tor the most part circumscribed in area, and both in this country, and on the Continent, only expand from time to time into limited epidemics. Etiology— The exciting cause is a specific contagium, and those cases whicli appear to originate de novo, probably always arise from the virus— often long dormant and for- 1 "Des Inflammations SpCoiales du Tissu Muqueux et enpaxticuWer de la ""i^^^'^Path'SL^^^^^^ l^esearches on the Diseases of the Stomach," ipJdemic°oTDS&ria^ the Epidem. Soc." Fehrnaiy. 1862. DIPHTHERIA. 125 gotten — of previous cases. Tender age is the ]}Tmci-pal predis- posing cause, but the accidental existence of pharyngeal catarrh, or of any disease which lowers the system probably increases individual receptivity. Family constitution also often exercises an unfavourable iniiuence. The natiural history of the contagium has not yet been elucidated. Some information has been obtained as to the atmospheric conditions and temperature under which the poison exists and flourishes, but considerable uncertainty exists as to the laws which govern its development and effect its diffusion. The mode or modes also in which the disease- producing virus enters the system, and its period of incuba- tion, have not yet been accui'ately determined. These various points will now be considered in detail. TJie NaturaV History of the Contagium. — The contagious principle has not been isolated, although it is highly pro- bable that it consists of minute particles of matter, which are capable of floating in the atmosphere, and attaching them- selves to rough surfaces {see Mode of Diffusion). The doc- trine has been put forth by Oertel, Hueter, Nassilofif, and Letzerich, that a minute fungus is the essential contagium. The views of these authors will be referred to in detail in treating of the pathology, and it is sufficient to state here that the observations are not sufficiently conclusive to warrant us in considering that the essence of the disease has yet been discovered. Low vegetable organisms probably play an important part in the propagation of the disease, but the exact relation between the disease and the organisms has not as yet been made out. The experiments of Oertel, Letzerich, and others, if uncontradicted, woidd only show that micro- cocci are an invariable concomitant of diphtheria; that they are the sole or even the main agent in its causa- tion cannot as yet be considered proved. Dr. Maclagan^ has, however, clearly shown that "the germ theory" explains all the phenomena of the specific fevers, and in a matter, which at present is beyond inductive proof, analogy is of the highest value. For a further consideration of this subject, the reader is referred to the section on Pathology. In considering the etiology of the disease, it is most im- portant to determine whether it can originate de novo or not. Although the disease so often arises in connection with bad drainage, foul habits, and impure water supply ; and although 1 " The Germ Theory," &c. London, 1876. 126 DISEASES OF THE THROAT AND NOSE. it is SO often impossible to trace the remotest cliaimel of con- tagion, yet the whole tendency of sanitary science is opposed to°the doctrine of the spontaneous origin of specific diseases. ^ It must not be forgotten that in those cases where the disease appears to enter the system through the use of drinking water contaminated with excrementitious matter, the specific crerms of the disease, derived from persons prcAaously sulfer- kio- from it, may have found then way into the water. 1 have frequently known the disease occur suddenly m remote country districts, where careful inquiries have failed to dis- cover the smallest evidence of infection, but similar phe- nomena are often observed in connection with scarlatina and .small-pox— diseases which no one would now attribute to a spontaneous origin.^ A very remarkable mstance of the apparently spontaneous origin of the disease was observed last year by Dr. Semon, at a smaU health resort, caUed Bad Fuscii" in the Tj^^ol. The place, consisting of only two houses, is situated at an elevation of from 3,000 to 4,000 feet above the sea, and is celebrated for its fresh air and pure water In one of these houses a little gud, five years of age, who iiad left Vienna five weeks previously, was suddenly attacked with diphtheria, which was subsequently foUowed hv iDaralysis. The visitors consisted almost entu-ely of tourists, ascending the high mountains in the neighbour- hood Although other chHdren had been playing with the little ^irl up to the day on which she was attacked, no other case of this kind occmTed. It need scarcely be said that the outbreak of the disease in this case may, however, also be explained in accordance with the theory of contagion. CKmatic and Atmospheric Conditions under lohieh the Contagium uZ and Flourishes.-Th. disease exists m almost every country but it is most common m temperate climates. The coAta^ium lives under ordinary atmospheric conditions, but it is probable that dampness favours its development. It occurs in the tropics, but does not appear to have been noticed in the Arctic regions. It seems likely that the gemis 1 Aitken cs- . <'<^lv+>i Re-DOi-t on Public Health," quoted by Dr. fer" The Sc^fncfS Prac^^^^ of Medicine." Sixth Edition. ^°^'D/kellv also states as the result of his experience as the sanitary of the Combined Sanitary Districts of West Sussex. DIPHTHERIA. 127 may remain dormant, external to the body, for a considerable period, and may only develop under the stimulus of some particular atmosplieric conditions,^ or when a suitable nidus presents itself. In making statistical inquiries, with reference to the registration of disease in sub-districts. Dr. Thm-sfield^ found in certain isolated hamlets and houses where in recent years he had been called upon to investigate cases of diphtheria, that at intervals of five, ten, fifteen, twenty-five^ thirty, and even more years, there had been previous outbreaks of fatal sore throat. An instance is recorded by Dr. William Squire^ in which the virus re- mained latent eleven months, and then led to the develop- ment of the disease when a person occupied the room in which a case of diphtheria had previously occurred. I have known the poison to remain dormant for four, seven, and fifteen months, and in one instance for three years, and then again to become active. From the above considerations the vitality of the disease-germs would seem to be considerable. In Great Britain the disease has generally been pre- valent in those parts of the country where the rainfall is great, in villages situated in valleys, or in places where there is not sufiicient fall to get rid of the surface drainage, but it has also been frequently met with, and shown great epidemic persistency, in high, dry, and exposed situations. The disease is much more common in rural than in urban districts. Whether, however, this fact points to the greater humidity which prevails in the country, or to the absence of proper drainage, is not at present certain. According to Dr. Thursfield,* whose experience as a sanitary inspector extends over twelve hundred square miles, " with a popula- tion of rather more than two hundred thousand, of which rather more than one hundred thousand are rural, the number of fatal cases of diphtheria in the rural portion is nearly three times that in the urban portion." The same author remarks that whatever conditions seem to promote fungoid growth, would appear to favour the incidence and persistence of the disease, and the explanation of the com- parative immunity of towns may be the presence of some- thing in their atmosphere inimical to such growth. Until recently the extension of the disease was considered to ^ Sanne : "Traite de la Diphtherie." Paris, 1876, p. 231 "Lancet," vol. ii. 1878. Nos. vi. vii. viii. 3 Reynolds' «< System of Medicine," vol. i. p. 379 * Loo. cit. ^ • • 128 DISEASES OP THE THROAT AND NOSE. be independent of season, but the observations of Wibmeri and Thursfield 2 tend to show that it prevaHs more extensively during the winter months than at other periods of the year. Many severe epidemics have, however, steadUy raged througli the whole round of the year in spite of the most varie.l changes of weather and temperature. . . Mode of JDyfwston.-Considerable difference of opimou exists as to the mode in which the poison is diffused, ihe disease may be imparted to others by a person actuaUy, or lately, snffermg from it, but the extreme difficiilty of effectmg artmial implantation would tend to show that du-ect con- tagion is rare. From this fact it would seem probable that the contagium, when set free from the affected in- dividual undergoes further development (as m the case ot cholera and typhoid fever), which increases its disease- oroducing properties. It is asserted that the poison may be conveyed by a person not actuaUy affected by the dis- ease Dr. Thursfield 3 has reported a very remarkable case" in which a woman living in an infected house, but not at any time suffering herself, walked a nule or two and crossed a ferry to visit a friend. She only remamed a short time in the house, but sufficiently long to leave the cerm of diphtheria, which broke out a day or two after- wards. This, however, is such an exceptional example, that the possibiUty of the malady having arisen from other sources must be borne in mind. In one instance I have known the disease caught from a patient who had entirely recovered from it foui- months previously, but whether it was conveyed by the person or the clothes of the individual, it was impossible to determine. _ In sohtary cases the contagium does not usuaUy assiune a vHulent form and proper measures are almost invariably successful in coding the disease to a limited area. The distance at which the contagious principle can operate as a rule appears to be more limfted than is the case in typhus or smaU- Dox Thus I have .known an instance m Avhich seven Sdren were affected in a house which had a i-esidence Tf^l side of it, and a third opposite at a distance of oSly twenty-four feet. Although in aU these buildmgs Untersuchungen iiber Diphthentis, p. 340. 2 Loc. cit. ' DIPHTHERIA. 129 there were young children, no other case of dijDhtheria occurred. Other similar illustrations of this fact are on record.i Under certain circumstances, however, the diffusive powers are increased, and, as apjjears to he the case in epi- demics of influenza, the poison may he wafted over extensive tracts of country. The germs of diphtheria appear to have an affinity for the walls of roomSj and, according to some ohservers, may attach themselves to clothes and articles of furniture. ^ It is probable that by the introduction of such things the poison is often diffused. Manner in which Foison Enters the System. — The poison may be received into the system {p) by direct implantation; {I) through the circumambient ah ; (c) through the water that is drunk, or the food that is eaten. Further, it is pos- sible that it may be occasionally introduced by inoculation, either with portions of false membrane or with the blood of a patient sufi'ering from the disease. (o) The melancholy deaths of VaUeix and Henri Blache,^ show that the disease may occasionally originate from direct implantation. M. See has reported a case of the same character, in which a woman suckled a child aff'ected with diphtheria. In consequence her own child, which she was niu-sing at the same time, contracted labial diphtheria, and communicated it to the mother, who frequently kissed her mfant. An instance of dhect implantation has been placed on record by Professor Bossi,^ in which a greyhound was seized with symptoms akin to those of diphtheria four days after swaUowing the excrement of a child who died of that disease ; after death a membranous exudation was found on the animal's fauces. ^ (&) The contagium which exists in the secretions and exhalations of the sick, may pass into the air and find its Avay directly into the healthy organism by absorption thi'ough ' Thiu-sfield : Loc. cit. 2 ganne • Op cit 4 ?T,°TTi "Cli^- Lectures," New Syd. Soc. Trans, vol. ii. p. 497 6 Q- 'les Hop." t. iv. p. 378. bu- J R. Connack: "Clinical Studies," vol. ii. p. 273- " Lo Spenmentale," 1872, p. 230. i-'O tratio,!:".^T5'^®''^°'' has placed on record a somewhat analogous iUus- wHch !v ^^""^ ^'"''''^ *° Pi«°^ °* ^^«te ground on 7.r^ rv i:rv '^^''^'^rg'es or concretions" of some patients sufFerin e- cation, enlarged submaxillary glands, and in one case with diDlXr K 130 DISEASES OP THE THROAT AND NOSE. the lungs, or tlirough the mucous membrane of the throat ; or the secretions of the sick may pass into drains, and sewer gas holding the disease germs in suspension, may be after- wards inspu-ed. ^ -, ^ i ^ / (c) The poison may be conveyed through food or water (or other fluid used for drinking purposes), as in the analogous case of typhoid fever. Here it may be mentioned that Bossis case, refen-ed to above, may be an example of the manner in which the poison is absorbed through the alimentary canal— not an example of direct implantation. In many of the cases of diphtheria which I have seen draing the last few years, the drinking water was found to be contaminated with excre- mentitious matter. As regards dhect inoculation with diphtheritic membrane the experiments made with false membrane, by Trousseau,^ Peter, and Duchamp,^ upon themselves, and by Dr. Cx. Hariey- upon animals, gave only negative results. In the experiments of Trendelenburg* and Oertel,^ on rabbits, a diphtheritic mem- brane formed in the trachea, as the result of du'ect untation of that part with diphtheritic matter, and the animals died on the second or third day, with acute kidney disease and symptoms of general infection. ITassdoff ^ and Eberth 7 have produced diphtheritic keratitis by direct inoculation, while Hueter and Tommasi^ and Oertel, in their experiments on the muscles, found that soon after inoculation a diph- theritic layer appeared round the edges of the wound ; h^moiThagic inflammation was induced m the muscles and the animals died on the second day from general blood- poisoning. Although in some of these experiments a false membrane was produced, the septicaemia may have been merely the result of inoculation with decomposing animal matter, and it cannot be considered that true diphtheria with Tspedfic manifestations has yet been artihciaUy produced by inoculation of the lower animals, though certam local phenomena of great interest and importance have been aTcw cases are on record in which medical practitioners are said to have been inoculated with blood i.e. to have becom infected through the accidental prick of a lancet smeaml 1 T>^^^ T, -^SS ^ "Pathological Transactions vol. x. p. ^lo. ^ feS. pa.... a.-^.^t'MS.^-'eii:57. ??e^,T. » Loc. cit. ° VircW s ' ' ArcMv." 1870, p. 560. ■ Oorrespondenz'blatt," 1872. ' Centralblatt f . Med. Wissenscliaften, 1868, p. 34. 1 u 8 New Sydenham Society's Translation, 1864. 146 DISEASES OP THE THEOAT AND NOSE. Of parts supplied by the lenticular ganglion of ^.e sympathy cliin, as the pharyngeal paralysis ^PPf.^f^^^^.^f "^^^^^^^^ Zl ' pairment of Meckel's ganglion, _ and these f^cts hav^^^^^^^^ L Hughlings Jackson Mo^i^^^^^^^^^^^^ T^^t^- paralysis for a '^o^respond^^^^^^^^ ifthe res^^ 5 d^Mheritic paralysis, but only slight mter- CVTh tieS r^Weafly show sig^J o, pa». Ws? The lower extemities are usuaUy the tot to he S ted. The patient tot suffers MTle^f h fte L'^er'e'^w^Con air. complete paralysis. „ - „„„ aenerallv those of the The last muscles to ^^^^f ^f^J/^^X^H^ ^orst forms which faUs heipiess^ ^^^^^ Paralysis of the latter re ^^^^^^^ considerable em- impossible, and at t^^^^^^ inipUcation of the mter- ^^rf'^^'^Pn SfSSragm is also paralyzed, as m i-are costals. _ .^^K is enormously increased, ^T.;' ?Jtt rS^^^^^^^^^^^ of dying from asphyxia. Hedical Jomnal," May 12, 1877, p. 506. DIPHTHERIA. U7 If, however, the paralysis be not complete, the danger may- be warded off, and the patient may gradually recover. Con- cm-rently with the paralysis of the extremities in the most severe cases, there is often incontinence of urine and fseces from palsy of the sphincters of the bladder and rectum. In men the sexual function is also affected in such cases, and the patient becomes temporarily impotent. Having continued for a period varying from six weeks to half-a-year, these paralyses gradually disappear in the order in which they appeared, the duration being in each case proportionate to the degree of paralysis. If no unfortu- nate complications lead to a fatal result, eventual recovery of muscular power may almost invariably be counted upon ; but in most cases the patient continues for a long time to experi- ence some degree of weakness iu the affected parts. Lastly, it is well to remember that the severity of the paralytic symptoms bears no proportion whatever to the severity of the antecedent disease. The loss of power may occur in a marked degree after even the most trivial attacks. Diagnosis. — In some cases of diphtheria an absolute diagnosis may be almost a matter of impossibility, at any rate ra the earlier stages of the disease. The difficulty generally arises in those cases which deviate from the normal type in the direction either of unusual mildness or of unusual severity. Very mUd cases, in which the false membrane is either absent or late in appearing, may easily be confounded with ordinary catarrhal sore-throat. The diagnostic criteria are both few and indefinite. A history of infection, or the epidemic prevalence of diphtheria, may in some cases be of service in forming an opinion, but more often the practitioner has to trust to other data. In the case of the diphtheritic sore-throat, without false membrane, the congestion is at once more limited and more intense than in pharyngeal catarrh ; it often affects one lateral half of the soft palate, or one tonsil, while the catarrhal process has usually a more general distribution. In simple sore-throat the surface of the tonsils may be covered here and there with patches of deposit, which might possibly mislead an ignorant or incautious observer ; but such deposits wiU invariably be found to be soft, semi-fluid, and easUy removed. They are, in fact, nothing more than the modified secretion of the congested mucous structures. In diphtheria, moreover, there IS often albuminuria, and a degree of prostration out of proportion to the severity of the local changes. In many 148 DISEASES OF THE THBOAT AND NOSE. cases, in the abseBce of false membrane the F^^J^^^^^^^^ rest content with a diagnosis founded ^^P°^ criteria. In other cases, however, the ^^f^^^^^^^^^^J^^^^ of exndation and the ^PP^a^'^^^^f , J^'^^^^l fj^^^^ general infection may clear up aU '^'^^^^ ^/^^^i, d^^ ^stances the supervention --^^ ^^^^^^^^^^ convalescence wiU solve the proBlem m i j manner. It is hardly necessary to add th«t, m aU cjes o^ suspected dipi*-;- ^' l^-ough etammatiL of the practitioner to make a most tnoioug „ossible hy Lerlor of the throat, ="PPl''=» j'^'f^^^ ^^^^^^^^^ ^- rXvSlV'S'gi™ ve?;nierl.lSelpUrds a satisfactory ^'ISries in which diphtheria appears iri an .<.«^P'»^f J sev'^: S ™y offer s^ g-^^'—'CS i^ P'^r tZ'diS C th? *ces U appear healthy, nature of the disease -c^vbu . . £ membrane and the case be stiU one of 'i^l™ ;^ i^^ve formed may not as yet have had txme to foxm oi ma^^^^^^ beyond tb^range of s^ht Th-^^ya^^^^ :piTemic »n' diphtheria very rarely occur, rn an no doubt that, rn --^^-'^S^^^ for scarlet fever, ihe severe con symptom in sore-throat, and the rash, ^^^^^^^ ^ ^Tto Sead the s.me epidemics of d.^^^^^^^^^^ ,,3 ^eU observer. But the points « ^ slighter marked. The <^^^^'f'^f;^ 'Z anorexia, but more in ^Vf^^^^^-'^lZS, l^scadet fever is uniformly red- prostration Jl.f ' t of any membraniform deposits, DIPHTHERIA. 149 known to occur in diphtheria, is not uncommon in scarlet fever. The distinctive characters of the rashes have abeady been described. Acute tonsillitis at its outset may simulate the inflam- matory form of diphtheria. In both there is considerable constitutional disturbance and difficulty of swallowing; in both the throat affection has a more or less unilateral tendency, and commences with intense congestion. In tonsillitis, however, the inflammation either subsides, or rapidly passes into suppuration, and thus removes all cause of difficulty. Confluent herpes of the throat is not a common disorder, and is not, therefore, often likely to give rise to diffi- cidties in practice. Trousseau,^ however, has laid down the diagnostic distinctions between the two diseases with considerable detail. Herpes is usually ushered in with considerable constitutional disturbance, but the temperature rarely rises higher than 102° or 102-5° Fahr., and it quickly subsides. ' The pain in the throat is of a peculiar smarting character. Herpes has no tendency to spread beyond the seat of its first efflorescence. Thus, if in a doubtful case the morbid process is found extending to the tonsils, to the larynx, or to the nose, herpes may be excluded. Of course the simid- taneous appearance of herpes on the lip will be of great help in forming a diagnosis. The diagnostic distinctions between laryngeal diphtheria and catarrhal laryngitis wiU be found under the head of " Croup." Patliolocjy. — The characteristic product of diphtheritic in- flammation— the false membrane — is a tough dry substance resembling fibrin, or the buffy-coat of the blood. In colour it is yellowish, or greyish-white ; it is firm and elastic, but it breaks across suddenly when stretched. The addition of acetic acid causes it to swell up and become transparent ; it is dissolved by caustic alkalies. It is insoluble i^i water, and yields to it neither gelatine nor albumen. It thus closely resembles fibrin in most of its qualities. The membrane may vary from a thin and transparent pellicle to a skin of considerable thickness. The character of the exudation varies according to its age. In the earlier stages the difi"erent patches of membrane are more or less isolated, they are surrounded by mucous membrane in a state of mtense hyperemia, they project only very slightly above ' Op. cit. vol. ii. p. 439. 150 DISEASES OF THE MEOAl AND KOSE. the m«cous sm-feoe, and they cannot he amoved withont consideKhle force. Later on the patches « '".^^^ ''tccortSt the most recent researches, the -^ndatdou in ?^^o a'p^:Xf oration ome ^ often seTn mL te extravasations of blood, which, ^gin1u;foS:d on the '^"^p^^^t^^XJ^^i ted froni " ;-*j;^;S';fi^tSivoXrBin/fleisch,' ?r«raJj5e|^^^^^^^^^^ wWer term i.e *Xl?p oc" « ^^-'^^ i Sergo the degene-tion^ I^s increasing qnantities separation of the false membrane, and ^^/^^'J, '° J,™™ "o some extent by latter. The exndation f^" Ss becoming nndergoing a process of sottenm grannlar and fatty, ''"f ™ . j,„t an uncommon nous degeneration. ihis, inou„ . ..Letobuch der P.M. GeweWeto," II. Aufl.ge, p. 310. Leipzig, 1871. DIPHTHERIA, 151 termination in favourable cases of tracheal diphtheria, is much rarer when the false membrane is formed in the pharynx. In describing the symptoms of diphtheria, it has been pointed out that in the earliest stages of the disease the mucous membrane is inflamed and swollen, but is soon coated with false membrane, and becomes hidden from view. If the disease progresses favourably and the case is not very severe, on separation of the lymph, the mucous membrane is seen to be smooth, and often somewhat paler, than in a state of health ; but, if the affection has been at aU violent, more or less ulceration of the mucous membrane will be present. Occasionally the morbid process does not stop at tdceration, but gangrene results, and there is considerable loss of tissue. In many fatal cases the gangrenous process is in active opera- tion, and its peculiar odour becomes evident on the post- mortem table, if not during life. The idea, entertained by the ancient physicians, that the disease was a gangrenous process was, it need scarcely be observed, derived from the appearance of the false membranes themselves, which, whether white or subsequently discoloured, have very much the aspect of an eschar or slough. This is, of course, only a delusive appearance, and our modern knowledge of the gangrenous process in diphtheria is based on the post-mortem examination of the tissues beneath the false membrane. In the severer forms of the disease there is, in addition to the changes above described, an exudation of fibrin into the sub- epithelial comiective tissue. The exudation and infiltration sometimes compress the nutrient vessels of the part, and thus arrest its blood supply. Necrosis of the involved tissues results, and leads to the formation of a slough, which is, in course of time. Separated from the healthy parts. On the slough becoming finally detached, there is left an'idcer of variable depth and extent. In several cases I have known the patient recover with the loss of his uvula, and with a portion of one or both tonsils destroyed. It is more common, however, in cases of recovery after gangrene to find large and puckered cicatrices resembling those which are seen as the residt of syphihtic ulceration. In addition to the inflammatory products of diphtheria, there are certain parasitic phenomena. The idea that diphtheria is of parasitic origin was first put forward by Professor Laycock ^ and subsequently revived by 1 " Medical Times and Gazette," May 29, 1858. 152 DISEASES OP THE THROAT AND NOSE. Jodin.i More recently OerfceP has maintained the parasitic theory with great vigour, and has been followed hy many Ger- man observers. Oertel contends that certain definite forms ot vegetable life, especially the sphericalbacteria, caUedmicrococa, and the smaUest forms of haderium termo, are mvariab y associated with the diphtheritic process. The greyrsh- white hoarfrost-hke patches which appear on the mucous membrane at the very commencement of the disease, con- taH he says, luxuriant growths of micrococci. Ihey are always present in diphtheritic membranes and they are also found in varying quantity ^.^^l^e blood, when- ever such membrane exists. The quantity of them present S any case, moreover, bears, it is affii^med, a d^^^ct re atioa to the intensity of the morbid processes; they ^^tip^J^s the disease advances, and dimmish with its retreat. Oertel states that the special form of micrococcus is never present in simple inflammation of the fauces or in mer- curial stomatitis ; but, that if the diphtheritic process supei^ venes on these disorders, it at once makes its appearance, and quickly displaces the more common forms of bacteria previoii^ly m-esent According to Oertel and some other expenmentahsts Pmiology) after the inoculation of tl^e — ™^ animals with diphtheritic exudation, it has been foimd that the micrococci force their way amongst the c^^^^^fXim crowd into the blood and lymph vessels, which they lendei im- permeable,infiltrate the muscles, and lead to then- degeneration, S even reach the kidney, -^^-^.^^^T^wf Xtth' which is so common a comphcation of diphtheria. Eberth Ls cTone so far as to declare that without m^crococc^ the e Tlteno 6J^^ia; while m Italy ^lacchi behev^s that a parasite is as necessary in the pathogenesis ^: '^^^ of S as the aidAfwm vitis is in the production ^^^^^f ^^^^^^^^^ crape Letzerich^ has found another inngns—the zygodes- , Wr&ro™tsd ,J senator, who I " De la nature et du toitement d» croup, eto."-" Eevue MM." &lu°^ .'Wiia f Me^cW- p. DIPHTHERIA. 153 has found the leptothrix huccalis in diphtheria, and who considers the minute round bodies described by Oertel (as the spherical bacteria) to be the spores of the leptothrix. According to Senator the same fungi are found in diphtheria as in ulcerative, aphthous, and mercurial, stomatitis. In Feb- ruary, 1874, I examined seven cases for epiphytes, and suc- ceeded in finding what is commonly described as " the lepto- thrix buccalis " in five instances. In every case, however, the fungus was in the superficial layer of the lymph. The importance of the presence of fungi in diphtheritic de- posits is coniroverted by Dr. Beale,i whose authority, as a microscopist, must carry great weight in this country. This observer maintains that " vegetable germs are present in every part of the body of man and the higher animals, pro- bably from the earliest age, and in all stages of health. . MiLLions of vegetable germs are always present on the dorsum of the tongue and in the alimentary canal." Dr. Beale further states 2 that "active bacteria introduced amongst the living matter of healthy tissues will die, although the most minute germs present which escape death may remain em- bedded in the tissue in a perfectly quiescent state." He thinks also "that there are very few morbid conditions that are unquestionably solely due to the growth and multipHca- tion of vegetable fungi "3 The changes which may take place in other tissues in the course of an attack of diphtheria are very various : The parotid and sub-maxillary glands which Dr. Samuel Bard * first pointed out as being frequently swollen, have been recently shown by Doctors Balzer and Talamon ^ to be the subject of distinct pathological changes. The cells of the acini are generally either swollen and filled with a homogeneous mucoid material, or replaced by quantities of small round cells. Here and there are also frequently minute collections of pus. The lymphatia glands of the neck are almost invariably found to be more or less enlarged. On section they are redder than natural, and there is an evident increase m their cellular elements. The tissues around them, "which during life were brawny and tender, are found at the autopsy to be infiltrated with serum and with 1 " Disease Germs." London, 1872, p. 65, et seq. - Ibid. p. 71. ^ Ibid. p. 78. * Loe. cit. 5 "Revue MensueUe." Le 10 Juillet, 1878. 154 DISEASES OP THE THROAT AND NOSE. scattered pus-ceUs. Often tliey present minute extravasations, wMe, in rare cases, considerable masses of blood have been found effused in the ceUular tissue surrounding the glands. The lungs may be the seat of very varied changes, ihe bronchial tubes are always inflamed-the inflammation eeneraUy being catarrhal, but sometimes purulent; m SanT cases, however, it is plastic and then mos com monly occuis on the fourth or fifth day of the disease On laying open the bronchi, the false menibrane i^ foimd attached to their waUs, or lying loose in their channels The membrane is never equaUy extended throughout the whole system of tubes, but seems to have a P^^f^^f^^^^^^^^^^^^ those branches which run in a vertical direction. The fact ot one of tSe lungs being bound down by pleuritic adhesion wild seem especiaUy Xo attract the morbid f direction. Exudation is not imfrequently found to extend to the Sest bronchial ramifications, in which case the alveoh ai^ Wly more or less implicated, and contain fibrinous threads u ceUs, and, in some cases, blood corpuscles. As a rule t^e Cgs are more or less engorged and CBdematous, espec aUy at their bases ; and frequently there are extensive Vf^^^ ^l Dueumonia of a low type, with emphysema, or more often Ler^Lsufiiation of the air ceUs^ in the immediate vacm^^^^^ . ?n other cases scattered lobules are found coUap^^^^^^^^/Ji^ of ail- from occlusion of the smaller bronchi, or one of the ?obes is the seat of more or less extensive puhnonary apoplexy. According to Peter,^ 59-50 per cent, of the cases of broncho- pneiimrnfa occur between the -ond -d the sixth da^ JiPart has often an appearance of perfect health, but, m cases Sre death has occurred from general blood-poisomng, its murcular tSsue is soft and friable, and contains scattered Tt IsatL of blood. Under the microscope t^e — fibres show signs of fatty degeneration, and the biooa s fl.S and Tarry. In other cases the opposite condition s sometfrnl Sd, coagula of -sidef le ^^^^^^^^^ ^''^ n-^ fhP pavities of the heart and m the large vessels. Srand lifoer are often perfectly natui'al, but oc- 1 Jenner : Loc. cit. p. 38. 2 "Gazette heMom. -.p.^.. iqkc Meio^: "American Paris," 1866 ; and other authors. DIPHTHERIA. 155 of the stomach may be the seat of ulcers and sloughs, and hfemorrhagic exudations are occasionally met with, both in that situation and beneath the lining membrane of the intestines and bladder. The kichieijs present marked changes in about half the fatal cases of diphtheria. They are swollen and engorged, and often contain scattered collections of blood. In other cases the changes are only visible under the micro- scope. Here the epithelial cells lining the tubules are found swollen and granular, and they have often undergone extensive proliferation, the crowded masses of young cells filling the tubes, and forming epithehal casts. Occasionally the Mal- phigian tufts and the tubules contain blood, and the latter are sometimes occupied by hyaline coagula. The changes in the Irain depend on the mode of death, and, if the patient succumbs to asphyxia, there is venous engorgement of the membranes and cerebral substance, and minute extravasations of blood. Pus and lyiaph have also been found on the arachnoid membrane, when the septicaemia has been vety marked. In many cases where death has taken place whilst the patient was suffering from extensive diphtheritic paralysis, the muscles have presented no marked alterations ;i andMorelli" goes so far as to say that "the anatomico-histolo- gical changes found in such cases are inadequate to explain the various forms of diphtheritic paralysis and paresis." In fact, the almost invariable restoration of these functions woidd seem to argue conclusively against these muscles being the seat of any serious degenerative change. In exceptional cases, however, serious and extensive lesions have been discovered. They were first observed by Charcot and Vulpian^ in a case of paralysis of the velum palati. The motor nerves of the part consisted of tubules emptied of their medullary substance, their neurilemma containing numerous granular cells, elliptical in form, and in some instances, nucleated. In one case Bulil* found the nerves thickened at their roots, and the sheathes of the nerves crowded with lymphoid cells and nuclei. In a case of Oertel's^ the muscles had undergone extensive fatty de- generation, while the substance of the brain, spinal cord, and spinal nerves was the seat of numerous extravasations of ^ See two cases reported by Dr. Hermann Weber: " Virchow's. Archiv." vol. xxiii. p. 116. * "Lo Sperimentale," Decembre, 1872. ^ " Compt. rend, de la Soc. de Biol." 1862. ^ Ziemssen's " Cyclopsedia," vol. i. p. 656. 5 Tbid. p. 657. ^ ' ^ 156 DISEASES OP THE THROAT AND NOSE. yarious dates. There were also other marked changes in the spinal cord. Dr. Hughlings Jackson has P^"^*^^ ^^J,,^^^^^ muscles supplied in part thr^ough ganglia of the ^J^V^'^^^^- system are' especially prone to be the ^^J^^^.^ of pa^^^^^^^ This is true of diphtherial amaurosis, and of the paralysi. S L plte, and It would seem that ^^^-^^J^^^f^Z^^ give way are most largely represented m the Ingher ganglia ''^:Zr^^7^^J0^ the general pathology of diph- theria suffices to assure us that it is an acute general disease, ^^th certaS local manifestations. The primary sephc- 7emia is in the first instance, to the specific poison hu absoSt on from the decomposing lymph is no doubt a s?a caiise of secondary infection. In all cases the tutTonal disturbance by which the attacks ^^^^f^^^ SrhSnTSt Sic g^^JS-m^be looked upon rSe rst^v^dence of constitutional poisomng. m fact, as 'V-'°f,%r ^iCrXp^heria varies chieBy ^TrroTwrof the patient and the character and re tf the ep i:nSV anJ ""^The^X :^;i; be /^orne in X/J- IT^^^^ — ' tive pi-oportion of 'l^^a'^so^er cent. According In some epidemics „ff ".^ent Plorentine epi- t„ Dr. Borgiottfs statis^ ^J^M. years 1873 and ■fsTrsM Id "ufTDr. Borgiotti elsewhere" remaAs .JlVZet^mplete^^^^^ rS^i tlo-otd t nS^af the delation of " the ...... ■affected to the dead.' 1 Loc. cit. - Loc. cit. . )i fc« -r, if5 3 "AttiAell Accademia, &c. p. lo. DIPHTHERIA. 157 The dangers which are most to be dreaded at the outset of an attack are, on the one hand, extension of the disease to the larynx, and, on the other, the severe blood-poisoning. In the former case the patient is exposed to imminent risk of death from asphyxia. In the latter a fatal result may occur from collapse, or the patient may rapidly sink with typhoid symptoms. At a later period, a fatal residt may be brought about by repeated attacks of syncope, by general prostration without manifest cause, by exhaustion from constant and un- controllable vomiting or from severe hasmorrhages, or by inflammatory compKcations such as secondary jmeumonia or acute nephritis. In the case of infants death has resulted from inability to suck, owing to implication and consequent stoppage of the nasal passage. Death during convalescence most commonly results from paralysis of the heart, or of the muscles of inspiration, or from intercurrent disease of the lungs or pleura, or from general failure of nerve-force and exhaustion. With regard then to the data on which a prognosis must be formed, the most important general consideration is the character and mortality of the prevailing epidemic. It may, perhaps, be laid down as a rule that of the cases in which a deiinite false membrane is present, one-third at least will prob- ably prove fatal. Apart from other less known causes, the mor- tahty in any epidemic will vary according to the form of the disease and according to the proportion of children to adults attacked, diphtheria being, for obvious reasons, far more fatal amongst children than adults. It must also be borne in mind that ia certain families diphtheria has an exceptional tendency towards a fatal result. With regard to the sjjecial symptoms on which to found a prognosis, the following considerations chiefly deserve attention: High temperature, extreme pros- tration, hfemorrhages, or urgent vomiting at the commence- ment of an attack are signs indicative of extensive general infection, and must therefore be looked upon as of very serious prognostic import. Valuable information may be gamed from the character and extent of the false membrane. Ceteris jparihus, the prognosis is serious in proportion to the thickness and extent of the exudation. When the exuda- tion shows a disposition to extend rapidly the danger is very considerable, as the extension is very likely to take place m the direction of the larynx. Prostration and a tendency to syncope are alarming signs at any period of an attack : their advent is often heralded by a very rapid or a very slow pulse 158 DISEASES OF THE THROAT AND NOSE. With muffling of the heart's sounds, ^^'i i^^^^^f^^^^^ pulsations. The presence of albumen is not as I pointed out, a symptom of a serious import. Durmg^conva lescence the extension of muscular paralysis to the muscles J: U to'a general hlo^d infectic. ^nA^ to a local specific i^^^^^^/^^te £ eacKe devia- processes appears to run a '^yf ^^^^^"^^^^^^^^ ^l^ich after iion from health is only a f^^^^^^ncy ^o subside lasting for a --f ^^^^^^ action, and to termmate m the J ^^^^^ special Each process, 1^°^^^^^^' "f/. , i„g,,e before the return to tstS tt geW coXon\t is the inten^ty ^Tlt J^lcC^lTyrhich constitutes the great danger; f ..^v th^risl hes in the occurrence of the exudatwn ^n locally, tHe risK uwb obiects ia the treatment, \^'f'''' :^t lo offer eTery po ible resistance to the therefore, -mil be to ^ This will be accom- Sir;Sf Cg°-> a%'rA ^ lo-l .ea^. and S 4 of 'Lt.e«„r «ected — General Treatment.— "l^^ .-^ritHpnt's strength by every husbanding and «-PP°^t;^S f ^ f pfssible"^ m a Wable « ^^^^^ of Mch large, cheerliU, ana wcu v temperature should must be at once warm and mo st ^ g^o 65° be kept as nearly f.% P«^ff f,/^^^Xe nutritious and has pointed ^^^^^^^ ^Tt^ch circumstances it must be com- these cases, and under ^ucn circ^ attention must be paid bined with hme 7^^^" Xn ^^^^^^^ power of the to feeding during t^e mgH .P ^^^^ patient is --^^J .^Ith r ses swallowing is attended distaste for food in otne ^...^io^aUy everythmg with considerab e l am^ y^^^^ It is, however, 11 r,,rn deU'Anffina Difterica." Napoh, 1875, p. 64. 1 '< Intomo alia Oura aeu DIPHTHERIA. 159 not constitute the most important part of the medical treatment. The administration of alcohol in small quantities is almost always advisable. In some cases, it is true, it may not be called for during the whole of the attack, but very often it supplies us with the best chance of saving the patient's life, and it must then be pushed ■with a boldness rarely needed in other forms of disease. Small doses of alcohol wUl usually be found sufficient in the earlier stages of an attack; two ounces of brandy or four ounces of wine in the twenty-four hours may be prescribed for an adult, and proportionate quantities for a child. In other cases, however, larger doses are re- quired from the very commencement. But whatever be the earher symptoms the physician must always be prepared to increase the dose rapidly, if the appropriate indications — attacks of syncope, irregular, very frequent, or very slow pulse, and delirium — present themselves. In these circum- stances a high temperature does not in itself contra-indicate the employment of stimulants. In all cases it is necessary to keep a careful watch upon the pulse, which will give invaluable information as to the need for alcohol. Eapid and fatal failure of the heart often supervenes quite suddenly and unexpectedly, and the first indication of such failure is the signal for the unsparing use of the drug. Patients suffering from the exhaustion and prostration of diphtheria bear large amoimts of stimulant without any of the usual intoxicating effects, and as much as twenty ounces of brandy have been given to an adult within twenty-four hours with manifest benefit. Champagne may occasionally be substituted for brandy, but this wine, in the active state of the disease, often causes pain in deglutition, and, as a rule, is more useful during convalescence. Whenever there are signs of approaching cardiac failure, it is important to keep the patient in- bed with his head low, and to interdict any movement whatever. The neglect of this precaution has often been attended with fatal results. Before passing to the strictly therapeutic treatment it is necessary to make a few remarks on blood-letting. It was at one time thought that general bleeding had a favourable influence on the spread of the exudation. Home strongly advocated it, and recommended in addi- tion the appHcation of leeches to the upper part of the throat. Bretonneau invariably used the lancet in his earlier cases. But experience soon taught him that deple- 160 DISEASES OF THE THEOAT AND NOSE. tion neither extinguislied the disease nor prevented the o'Uw false memWe, and he f -^-^1^ f^^^^^^^^ it Gnersant, Trousseau, Bouchut, and Empis all came to a shmlar conclAsion, and since their time the treatment by v^section has not been revived. Considering the serious venesecuon aab g^cope and exhaustion to which pStsl tposedThers Xing from diphtheria, it is a Tatter for wonder that such treatment was ever thought of Thronlv rational excuse for its adoption was the theory that it meWed the extension of the local process. It has now, hoCer heen almost universally admitted that general hlood- kttiS has no influence whatever, unless it he an injurious one upon the exudation. The same may be said, with scScel? less emphasis, of local depletion The apphcation of Teeies to the throat may indeed reheve the pain and sweS^^U such relief is dearly bought at the loss of even smaUquantities of blood, and the serious risk of diphtheritic ^^f r ' ^t^r^ies which have been recon. JuL in diphthetia th^^^^^^^^^^^ g recuperative agents; (i) tne aue ea -K^^^^^cS^r«^^^^^ '^7^\^"^"lZrecuperative agents ii-on and quinine are the the most /^I^^^^Xam for provSg its value in diphtheria, n ISid "Sered 'frequently and in large dose. Tloi^W of the tincture of the perchloride may be ^ven Wult"ry two or three hours, and proportionate doses to tent is equally weD^arked, jrXrtacrdos^ the throat being procured by prescrib- The double effect is more ^^^g F^^^^^he less astrin- '"-r^ tlS' 'S:^e Vo^^^^^^ required in the gent V^^''f^^,,J^^^ The special indications course of an attacK oi temperature, vomitmg, for its use are l^^^^f^^^!"^^ • in such cases the 1 « Medical Times and Gazette," May 29, 18o8. DIPIPHBRIA. 161 sisted in if benefit fails to result in thirty-six or, at the most forty-eight hours. As a rule, however, quinine is more useful after the more serious symptoms have abated, when it may be very suitably combined with iron and a mineral acid. Morphia and chloral are occasionally necessary to combat continued sleeplessness, and to ward off the exhaus- tion which is its invariable consequence. (2.) The principal alleged specific remedies are : mercury, sulphide of potassium, bromine, and the balsams of copaiba and cubebs. The treatment of diphtheria by mercurials was at one time not less common than the practice of depletion, and it received a certain degree of support from the favourable influence which dusting with calomel is found to exert on diphtheritic wounds. But experience has long taught us that the general influence of mercury on the system rather promotes than checks the spread of the exuda- tion. At one period mercury was vigorously pushed by Bretonneau,! but with very unsatisfactory results. From that time the use- of mercuiy has been graduaUy discarded, and with such general consent that no one has since ventured to re-mtroduce it. Of the other alleged specifics, sulphide of potassium has long been regarded by Swiss physicians as a valuable specific, but it often produces both sickness and diarrhoea, and should not be employed. Bromine, which is best administered in the form of bromide of potassium, has not answered the expectations of its first advocate.2 The weU- known action of copaiba and cubebs on the mucous surfaces, led Dr. TrideauS to try these remedies in croup and diph- theria, and his experiments have been stiH further elaborated by Bergeron.4 Dr. Beverley Eobinsonf' has also lately strongly recommended the use of cubebs in the catarrhal form of diphtheria. This physician lays great stress on the importance of making use of the freshly ground powder in cataiThal cases I have found distinct benefit from the nse of the perles of copaiba. Ifone of the various drugs just enumerated, however, can legitimately lay claim to anv- tJimg like a certain and specific action. rnn'orc^rm""^ Diphtheria," from the imtings of Bretonnean anersant Trousseau, Bouchut, Empis, and Daviot. Selected translated hy Eobert Hunter Semple, M D. London, 1 859 7r, 77 Q ^ 5 W three hours. ^ Gre^-;;^:V\SereI internally ui of Erlangen, for ^^l^. ^^^^7^^. ^hese observations leqxme haH-grain doses ejery hour but ^.^i, have also confkmation. The salicylates of soda an p ^^^^^^ been strongly recommended. I ^^^^^ ^^^^^ ^he disease remedy in two cases, ^^^^t. Salicylate of was too far advanced for ^^^^^^ ^^^^'^ found useless soda and sahcylic acid ^^^^^ jTj^^^f^Jspectively.^ by Drs. Cadet de ^assecourt and Bergero^^^ p .^^^ ^ ■ The Mites mttoduced by Polli ('i^L^f i,/°S?ku™'.^i {■erriui ("tose p»pe" "•Jf"™" . , .« 5 Jotirnalfuri'raKiibo ^g^g_ DIPHTHERIA. 163 Archer i nearly one himdxed years ago. It has since been freqiiently employed in this country, and is highly esteemed by Dr. West.- A dessert-spoonful of the officinal in- fusion, sweetened with a little syrup, should be given every two hoiu's, but the eifect of the remedy should be watched, and the quantity reduced if any vomiting occur. Carbonate of ammonia (two or thi-ee grains) may be given with the senega, or it may be administered in water. The balsams of copaiba and cubebs, though placed under the list of alleged specifics, probably act in a gi-eat measure as expector- ants. Local Treatment. — This has varied greatly at different times, and there still exists considerable divergence of opinion as to which method is most appropriate. Caustics and astrin- gents, solvents and antiseptics, heat and cold, have all been in favour at different times and with different observers. The use of caustics has, perhaps, been more general than that of any other class of local apphcation. Breton- neau ^ strongly recommended a mixture of hydrochloric acid and honey, in the proportion of one part of the former to three of the latter, as a means of checking the local exudation. The caustic was to be applied only once in twenty-four or thirty hours, and its effects were to be carefully watched. Subsequent experience has shown that besides being attended with very considerable pain, the use of strong hydro- chloric acid has no effect in controlling the spread of false membrane. The use of a solution of nitrate of sHver, and even of the soHd stick, at one time met with con- siderable support, and has been recommended by Bretonneau, (^uersant, Bouchut, and Trousseau,* but it is being graduaUy abandoned by those who have had experience of recent epidemics. The same remark is true of sulphate of copper, and the acid nitrate of mercury, both of which have been recommended for the local treatment of diphtheria. In fact, the profession has given up the use of caustics alto- getber, bemg convinced that they rather aggravate, than check, _ the local process. Various astringents, such as tannic acid, powdered alum, or perchloride of iron, have been used for many vears, and stm are largely employed. Tannic acid and alum are most ^ Op. cit. 3 '<'^f'''-'°*^-^''°J''^°'l<^^il Most physicians in this country who have had the opportunity of studying the disease in the wards and in the deadhouse now regard croup as ^ fo™i„°|^P^- theria. At an early period Dr. George Johnson Bnt. Med. Jo}^- ,f ^b^ la, 1^701 maintained the identity of croup and diphtheria; and later, our gieat Jurdoa?t™ohS Sir William Jenner ("Lancet," Jan. 2 and 16, 1875) gave m his aSon to this doctrine. The renUed Traube of Gennany, had previously accepted the unity theory (Berlin " Klin. Woohenschrift," No. 31, 1872). The advocates of the duality theory have based then- views (1) on the supposed pathological differences, and (2) on the alleged clinical differences. (1 ) The supposed pathological differences in the struc- ture ' of the two kinds of false merabrane were formerly put forward as matters of great importance. _Vit- chowi the originator of these hypothetical distractions, thou<^h admitting that the diphtheritic exudation was°very sunilar to that of croup, mamtamed that the former was poured out into the substance oi the mucous membrane, wHle the latter was only a coagulation upon its sraface. On this hypothesis he founded what was once esteemed a most important point in practical diagnosis. The diphtheritic membrane, he asserted, could not'' be removed without tearing away_ . portions ot the underlyuig tissues, and leaving a bleeding surface. Ihe 1 " Archiv." 1847, p. 253, et seq. LARYNQO-TRACHEAL DIPHTHERIA. 17S croupous pellicle, on the other hand, could be easily detached,, and the denuded surface would be found quite healthy, Avith the exception, perhaps, of a variable degree of hyper- i\3mia. Before long, Virchow found himself compelled to surrender this distinction, as it was found in practice that the two forms of exudation passed into each other by insen- sible gradations. He now changed his ground,^ and promulgated the view that death (necrosis) of the subjacent tissues was the characteristic and essential feature of diphtheritic exudation. Practically, however, this distinction was found to be no more satisfactory than the former, for cases came under observation which cHnically answered to croup, but in which there was distinct death of tissue. It was also pointed out that the difference in the degree of adhesion of the croupous and diphtheritic exudations is due to the difference in the structure of the parts on luhich theij are thrown out. The false membrane is naturally more closely adherent in the pharynx, where the epithelial layers on which it is deposited are not marked off from the subjacent tissues by any definite homogeneous basement membrane. On the other hand, in the larynx and trachea the presence of the basement membrane favours the separation of the lymph. It has thus at length been generally admitted that there are no sufficient naked-eye appearances to distinguish the croupous from the diphtheritic exudation. ISTor have microscopical observers met with any better success in their endeavours to differentiate the two diseases. Dr. E. Wao-ner ^ who has done the best work in this direction, has openly- declared that his preparations of croupous and diphtheritic membranes are very much alilce. The diphtheritic deposit he describes as a transparent, homogeneous, lustrous network, the interspaces of which are, for the most part, filled with lymph and pus corpuscles, though some of them are void of contents. The croupous membrane consists of a close network of delicate threads, the meshes of which contain numerous elements resembling pus cells. Wagner, how- ever, differs from many other observers, holding that the network in both cases has its origin in a pecuhar fibrinous degeneration of the epithelium, and not in the separation of a coagulable fluid from the blood. Eindfleischs admits that nno "f^'i'^^buch der Spec. Path. -unci. Therapie," 1854, vol i d 292. See also " Berl. kl. Wochenschrift," 1866, No 2 ' ^' 2 "Archiv. der Heilkunde," 1866, vii. p. 481. o'lf^^^"''^ Pathologischen Gewebelehi-e." Third Edition pp. oil- 12 ' 174 DISEASES OF THE THBOAT AND NOSE. the patliological process in " pharyngeal croup " is the same as that which takes place in " laryngeal croup,' and thus gives in his adhesion to the views maintained m the present article : but in spite of their anatomical identity, he feels bound to oppose any clinical fusion of the two diseases. It wiU be seen from a consideration of the above facts that the patholgical differentiation of the phenomena must be abandoned. ^STheScal differences. The supposed .Hfferenoes are (a) The site of the disease ; and 4 its manifestations. _ la) Diphtheria is said to be an affection of the phaiynx occaBionaUy [aj Ajvpm.u.mra ig asserted, is essentiaUy a spreading J° t^'t^^y^'tTa^hea The fact is, that croup is a disease iSclmoiy c^enS^'t the pharynx, and only in about 10 Tr l^Ver^rt of cases originates in the larynx or trachea. Difference of site moieover, in a constitutional disease does not constatute a snecmc Sfference. Cancer is always cancer, whether the pharynx alone or fte larynx alone, is affected, or whether the two parts are attacked at the Wie time or consecutively, and i;heumatism is stiU iSism, whether it affects the heai^ or the anMe. (b) As regards the mamfestations of the disease . . . „ 1 7roup is said to be a local disease, 2) to be a sthemc inflam- mition S^ which (3) the lymphatic glands are not affected; and ^t in which there is no albuminuria, nor (5) paralysis ; whilst ^ flTSheria is a constitutional disease, (2) of '^.dj^amic type, m wM^ {3)Te cervical glands are inflamed, and (4) m which there ib no albuminuria (5) nor paralysis. m nTtSf'tJafil^^oup the general symptoms are not so ^ ' CO w>,P^, the membrane is thrown out on an extensive portaon 7tll tS "STdmits of ready explanation, on the view ^afthe seSTsymptoms are in part secondary to the local processes. For wMst tte Khatics of the mucous membrane of the soft palate, T^SLTlS^s^^J^ rho^S^T^lanl ^ W te trachea, are convened only t^ and the SaH gland at the side of g:eaterhorn of the h^oid W^^^^^^ less Uability to general the trachea^ focal Socess has seized only on the latter parts, iofeotion when the 1°°^ 5^°°?^'^^^^^ owerf\d the constitutional When the P"^^^^'^^?^,^ ^Xd^ so-caUed croup as in diphtheria, symptoms are however, as mar^^ ^^^^^^ S"''^°itfSS Ou Z other hand, there are medical remark apphes to diphthma^ u ^ diphtheria with rucceS° t'^i'tioS^ba^ed on diffUces of type in the two ^7r4^rce^cTJ^tL not often affected in croup, becauBS the mSL^ meSi^of the lai-ynx has no communication with the ,^^S:^ZSt'ut!'6Ll\'% S^e patients recovered-most of them in twenty-four hours. . LAEYNGO-TRACHEAL DIPHTHERIA. 175 superficial cervical glands ; on the other hand, as stated above, there is ail elaborate connection between the phaiynx and the lymphatic glands. [In cancer of the pharynx also the cervical glands are always enlarged, whilst in cancer of the larynx the glands are seldom at aU. aflfected.] (4) In croup albuminuria is often present. (5) Paralysis is rare in croup, because nearly all the cases ter- minate fatally, but it is occasionally met with in those that sm-vive. I have entered into these details because details must always have a certain amount of significance ; but it is more satisfactory to look at the question from a broad and philosophical point of view. Classifications are, after all, mere arbitrary arrangements by which knowledge may be placed ia an accessible form for further use. The oldest classifications are purely symptomatic. When anatomy came to be mastered we had an anatomical basis for classification, and we are still obliged to make considerable use of this system ; but as medical science progresses the disposition is to track disease to its origin, and seek out its hidden causes. Hence we see arising at the present day an etiological classification. The eause of disease, when it can be discovered, is now regarded as the essence of its specific nature. The ordinary inflammation of mucous membranes is attended with engorgement of the tissues, and the f onnation of pus on the surface ; under the influence, however, of a certain poisonous contagium the inflammation, instead of being attended with the formation of pus, leads to the exudation of layers of lymph, which become adherent to the free surface of the mucous membrane. This disease is called "diphtheria," and whether the lymph is deposited on the mucous membrane of the pharynx, or laiynx, or trachea, or bronchial tubes, or any other mucous membrane, or on a wounded surface, the disease is stOl " diphtheria." To suppose that there are two kinds of pellicular inflammations of the larynx, one in which the cause is the diphtheritic poison, and the other in which the cause is some other undiscovered influence, is totally opposed to all probabilities. Etiology.— This has already been discussed under diph- theria. Symptoms. — The disease develops in three different ways. It may originate in the larynx. This is typical croup, and prohahly does not occur in more than 10 or 12 per cent, of cases. 1 Most commonly it commences in the pharynx, and extends downwards, constituting descending croup. Occa- sionally, hut very rarely, it commences in the bronchial tubes or trachea, and ascends into the larynx. This is ascending croup. If, as is commonly the case, the disease commences in the pharynx, the practitioner wiU be constantly on the watch to note the first invasion of the larynx, but in typical croup, or primary laryngeal diphtheria, it is otherwise, and 1 See Sanne : Op. cit. p. 195. Sanne gives 142 cases out of 1 172 Compare also Simon : " Nouveau Diet, de M6d. et de Chii-. Prat." * 176 DISEASES OF THE THROAT AND NOSE. the symptoms of croup have been conveniently divided into three stages. The first stage is often preceded \>j slight catarrh. _ So insidious is the invasion of the disease that the serious character of the chHd's iUness is often quite unsus- pected. The little patient is noticed to be languid and feverish, he is thirsty, and refuses food, and at the same time there is slight hoarseness, which the nuise attributes to an ordinary cold, until her apprehensions are aroused by a frequent, short, dry, shi'Ul cough. The voice, which was at first only a little harsh, very quickly loses its resonant character and becomes a whisper. On examining the chest, both the inspiratory and expiratory sounds are found to be prolonged, and the normal respiratory mm-mur is lost in the laryngeal stridor which occm-s in inspiration. The supra- clavicular spaces are usually somewhat more depressed during inspiration than in the condition of health, and the slight difficulty of breathing which is present is more marked during sleep. The pulse now becomes considerably increased in frequency, and the febrile symptoms generally more pro- nounced. If a laryngoscopic examination can be accomplished, the mucous membrane of the larynx is seen to be of a bright- red colour, and when the disease has existed for a few hours some thin patches of false membrane may be perceived on the mucous membrane of the larynx. The usuaUypendent position of the epiglottis in childi-en often prevents a satisfactory examination even in those of tractable disposition ; but the timidity of early life is in itseK often sufficient to render the employment of the laryngoscope impossible. It is most important at tHs stage of the disease to make a very careful examination of the sputa. Children very often do not expectorate at aU, but anything that is brought up must be put into a glass vessel and gently shaken with a little pui-e water. The mucus dissolves, and fiocculi or smaU shi-eds of false membrane, if present, become visible. _ The second stage is characterized by mcreasing dyspnoea, and by the attacks of suffocation which suddenly supervene from time to time. When the attack comes on the child is generaUy found sitting up in bed, with red and swoUen face, and an anxious, terrified look. The nostrils are rapidly working, inspiration is hui-ried and " croupy and is evi- dently performed with the greatest difficulty, aU ttie auxihary muscles of inspii-ation being called into play. The voice is almost inaudible, and there is a constant hoarse and stifled LARYNGO-TKACHEAL DIPHTHEEIA. 177 cough, without expectoration. The attack generally lasts three or four minutes, and the patient subsides into a heaA^ sleep which often continues for several hours. Sometimes xmmistakahle pieces of membrane are thrown up with the cough, a phenomenon which is often most important as a means of diagnosis, as in many children suffering from laryngeal diphtheria there are no patches of exudation to be detected on a casual inspection of the fauces. It is only on carefid and persevering examination with the laryngoscope in cases favoiu'able for examination that the membrane, Avhich is the source of aU the trouble, can sometimes be recognized adhering to, or perhaps lying loose, in the chink of the glottis, and obstructing the passage of aii\ Occa- sionally the vomitiug which is induced by the constant fits of coughing, or by the administration of emetics, may lead to the separation and ejection of large pieces of membrane, in which case the urgent symptoms of dyspnoea are often most strikingly relieved. The mode in which sepa- ration takes place is exactly the same in the larynx and trachea as in the pharyngeal region; the process, however, is rendered easier by the arrangement of the mucous mem- brane, which, in the trachea and in the lower parts of the larynx is separated from the submucous tissues by a distinct basement membrane. But the improvement due to the expulsion of the concretions is generally only temporary ; exudation again collects, and the symptoms return in greater intensity than before. At this stage of the disease the pulse is very rapid, and generally irregiilar. The little patient is exhausted and is constantly bathed in sweat. Tim third stage now supervenes. As the disease advances the suffocation becomes more urgent, and there is no remiss-ion betiveen the attacks, the dysjmcea being constant, though fearfully aggravated every few minutes. The lips assimie a livid colour and the naUs become blue. The sternum and the intercostal spaces are forcibly draAvn inwards during each effort at inspu-ation, whilst the agony of impendmg suffocation is most distressing to witness. The child tlu'ows his arms wildly about, or clutches his throat to tear away, as it were, the obstruction, or he tlu-usts his fingers into his mouth to seize the offending substance. The ■symptoms of fever are intensified, the thirst is urgent, the tongue thickly furred, and the pulse quicker but weaker. The little patient dies in an attack of dyspnoea or soon succumbs to gradually mcreasing coma, to syncope, or exhaustion. N 178 DISEASES OF THE THROAT AND NOSE. Diagnosis. — Li children it is sometimes very difficult tf) distinguish catarrhal laryngitis, of a severe form, from croup. Indeed in the early stages it is often impossible to differ- entiate the two affections. In young children, from the small size of the larynx, and the great tendency to reflex irritation, slight inflammation of the larynx quickly gives rise to spasm, and produces stridulous iDreatliing, laryngitis stridulosa, as it is teclinicaUy caUed. When, however, the disease is fuUy developed, the two affections are easily distinguished, for whilst catarrhal laryngitis nearly always ends in recovery, in diphtheria the prospect of a fatal termination is soon apparent. Croup very often commences at night, but catar- rhal laryngitis ahnost invariably comes on at that time ; hence we have in the time at which the disease first mani- fests itself a possible diagnostic sign. It has already been pointed out that the laryngoscope cannot often be success- fully used in young children, but the expectoration must be examined in the way already described, and false membrane, if present, will always be detected. Further, there is a pure neurosis, a spasmodic action of the adductors of the vocal cords, giving rise_ to laryngismus stridulus, which has been caUed "spurious croup," "false croup," and "nervous croup," with which true croup is sometimes confounded. This disease very frequently comes whilst the mother is suckling, or dand- lin<^ the child. Carpo-pedal contractions also occur in marked cases of laryngismus, but above aU there is tU absolute intermission of aU dyspnoea between the paroxysms ; whdst in true croup, when fuUy established, slight dyspnoea is always present between the attacks of suffocation. Many fatal cases of laryngismus, however, no doubt lose theh quahtative aftix and appear in the Mortality Eeturns as simple " croup. ' Pathology.— Th.e false membrane does not differ essentiaUy from that described in connection with the pharyngeal form of the disease. The membranous exudation is more frequently found on the epiglottis and the ary-epiglottic folds than on the lower portions of the larynx, but occasionally it invests the whole of the lining membrane of the larynx, extends throughout the ventricles, and passes along the trachea to the smaUest ramifications of the bronchi. It rarely happens that the lymph is so abundant as to completely occlude the larynx, and in many fatal cases only a very thm, transparent membrane is found. The dyspnoea in croup is primarily due 1 The above considerations tend to show that the substantive use of the word " croup " is altogether objectionable. LARYNGO-TRACHEAL DIPHTHERIA. 179 to tlie inflammatory tumefaction and plastic exudation, which, however, soon gives rise to spasm of the adductors. The muscles are infiltrated with serum, hut there is no paralysis of the ahductors, nor atrophy of their structure. ^ The lymph is also more closely adherent in the supra- glottic than in the sub-glottic region. On removing the Ijrmph the mucous membrane is generally almost normal below the level of the vocal cords, but above that line it is often swollen and inflamed, and sometimes ulcerated. It has already been stated that the membrane which forms in the trachea can be much more easily detached than that which is found in the pharynx. There is nothing special as regards the false membrane in the trachea, which is generally more adherent, in the upper than in the lower portion of the tube. Prognosis. — The prognosis is most unfavourable. Probably not more than 10 per cent, of the patients recover under suitable treatment without tracheotomy. In this country tracheotomy is, comparatively, so little practised in croup — in proportion to the number of cases — that nearly aU the remainder prove fatal. If, however, the remaining 90 per cent, ■were tracheotomized, 66 per cent, might recover according to the most favourable statistics (see Note 3, page 183), or, accord- ing to an average, based on 4,663 operated on in the Children's Hospitals of- Paris, 23-91 per cent. Accepting the latter flgures, out of 100 cases of undoubted croup we might expect that 68-49 would terminate fatally, and 31-51 recover — 10 without tracheotomy and 21-51 {i.e., 23-91 per cent.) after the operation. If the trachea were not opened in the proper proportion of cases the fatality would, of course, be propor- tionately greater; whilst if the operation were performed earlier than is commonly the case, the mortality would probably be considerably less. The fatal termination may be expected in the first three or four days, certainly within the first week. Treatment : First Stage.— ThQ clrild should be placed in a warm, weU-ventilated room, an ice-bag should be applied to the neck, and ice constantly sucked. "Spray inhalations of lactic acid (tt|_xx ad ij.) should be employed. The inhala- tions should be given at least every hour, and continued for five mmutes at a time. In the second stage, or as soon as It IS believed that false membrane has formed, emetics employed. A number of instances are recorded m which children have been saved from imminent asphyxia by the spontaneous expidsion of false membrane, and this 1 See an interesting case recently pubHshed by Dr. Baginskv- Central. Zeitung fiir Kinderheilkunde," October 1, 1878. ' 180 DISEASES OF THE THROAT AND NOSE. natural Biode of cure lias sometimes been happily imitated by the admijiistration of emetics. According to VaUeix in thirty-one cases so treated, fifteen recovered, whUst ot tAventy-two in which tliis class of remedies was neglected, only one cure resulted. Trousseau concurs with the state- ments of VaUeLx. In many cases, howevei^ the I'ehef is merely temporary, the membranes quickly reforming m the larynx, and the dangerous symptoms returning Avith increased severity. Moreover, the practice is not altogether unattended by danger, for, the tracheal membrane may be forced up by the act of vomiting in such a way as to entn-e y obstruct the passage of air. This risk must be mcuiTed though vah- able time should never be wasted on the use of emetics, when the only alternative is the performance of tracheotomy. Tickling the fauces wiU occasionaUy be sufficient to excite the desired action, but as a rule it is necessary to resort to dru(TS Cardiac depression is so common an accompani- ment' of diphtheria that it is unwise to employ any emetic by which it is Ukely to be increased. iartar emetic must, therefore, be especiaUy avoided, fetrange as it may seem, this drug has in times past been very widely em- ployed in diphtheria. Trousseau,^ indeed, strongly con- demned its use, terming it the most dangerous of aU emetics. But Bouchut,3 as late as 1859, published three cases in which he attributed a successful issue to the energetic employment of tartar emetic. His example should not be followed, especiaUy as we have at our command emetics ^l^ich are not less certain iii their action than antmony. ShoiUd the practitioner distrust the efficacy of ipecacuanha, _ it is quite open to him to add from fifteen to twenty grains of sulphate of zinc. If the administration of these agents is not quickly followed by vomiting and the expulsion of the membJane it is useless to repeat them, and even where the breathing has once been temporarily reheved bj Their use, it is very questionable whether they should be a7a"n employed. In no case should the physician place ton much reliance upon them. When it is judged that there is false membrane loose m the l^'ynx, the removal of the membrane by direct mechanical meVnsSokd be attempted. The best ^^^^^^^^ this purpose is a brush attached to a piece of of ato^un wire. Instead of the common laryngeal brush I use one 1 Gidde du Med. Prat." t. i. Ai-t. " Diphtherite." 2 Trousseau : Op. cit. vol. u. P- 678. 3 " L'Union Medicale," Apiil 5th, 1859. LARYNGO-TRACHEAL DIPHTHERIA. 181 made of squirrel's tail. The hairs cover the sides of the laryngeal portion of the brush, and are directed upwards. As the laryngoscope cannot generally be used, the brush, guided by the forefinger of the left hand, should be carried down into the interior of the larynx. The windpipe can generally be freed from exudation by to-and-fro movements combined with a certain amount of rotation. I have several times employed this brush with marked advantage. Even if the practitioner is successful, however, in detaching por- tions of membrane, fresh exudation often recurs. I must here briefly refer to the subject of catheterism and " tubage " of the larynx. Catheterism was first recommended by Loiseau,! as a means of removing false membrane and introducing remedies into the windpipe. I have only to say that the false membrane can be much more easily removed with a proper croup-brushy and that solutions or powders can be more readily applied with a common laryngeal brush or insufflator. "Tubage," introduced by Bouchut,^ consists in the introduction of a small tube, from three-quarters of an inch to an inch in length, and leaving it in the larynx. It causes so much irritation that it cannot be retained, and its use has been quite given ujj. It is at the close of the second stage of croup, when inhala- tions and emetics have failed, that tracheotomy is called for. Marked recession of the sternum and chest walls is the indication for its performance. The credit of having been the first to establish this operation on a secure basis as a justifi- able part of the treatment of croup is due to Bretonneau,^ who published his first successful case in July, 1825. Ten years later Trousseau * reported that he had performed the operation thirty-six times with nine recoveries. From this time the position of the operation was secured, and it has since been performed many thousand times in France alone. Before his death, Trousseau ^ published a series of 466 cases in which the' operation had been performed in the Children's Hospital in Paris, between the years 1849 and 1858. Of these, in spite of unfavourable surroundings, 126, or more than 1 in 4, recovered. Later statistics have given still more favourable results. In 1863, Fischer and Bricheteau 6 » "Bull, de I'Acad. de Med." 1857. - Ibid. Sept. 1858. J Bretonneau: " Memoii-a " (New Syd. Soc), p. 59. * Trousseau : Ibid. p. 243. 5 Trousseau: "Rapport a I'Acad. de Med."— " BuU. de TAcad de Med." vol. xxiv. p. 112. " "Nouveau Dictiounaire de Medecine et Chirurgie." 1869, vol. x. 182 DISEASES OP THE THEOAT AND NOSE. collected all the facts -within their knowledge at the Hopital des Enfants Malades, the Hopital Sainte Eugenie, and in the city and the provinces, and the general results Avere as follows :— At the Hopital des Enfants Malades the operation had been performed in 1,011 cases, and the proportion of recoveries was 1 in 4 ; at the Hopital Sainte Eugenie the proportion was 1 in 6 } while the facts collected from other sources, though confessedly incomplete, showed in Paris 1 cure to 2-6 cases, and 1 to 3-6 in the provinces. According to M. Sanne, however, who has published the most extensive statistics from the Paris hospitals, during recent years the proportion of recoveries after tracheotomy has been less favourable, especially at the Hopital Sainte Eugenie, as will be seen from the appended tables ^ : — HOPITAL sainte EUGENIE. Years. Operations for Croup. 1864.... 1855, . . . 1856. .. , 1867. . . . 1858. . . , 1859. . . , 1860... 1861. . . 1862.. . 1863.. . 1864. . . 1865.. . 1866. . . 1867. . . 1868. . . 1869. . . 1870.. . 1871.. . 1872. . . 1873. . . 1874. . . 1875... Dis- charged Cured. Dead. Left uneured. Total. 2 7 0 9 4 9 Q. 13 5 19 0 24 5 24 1 30 23 95 4 122 17 88 4 109 7 31 2 40 16 45 3 64 23 67 7 97 35 68 3 106 26 85 4 115 44 87 6 137 36 76 3 116 29 63 4 96 31 101 3 135 31 70 2 103 42 85 4 131 12 78 3 93 39 138 10 187 32 170 11 213 23 132 7 162 27 175 9 211 509 1 1713 90 2312 Proportion of Curei. in 4-50 3- 26 4- 80 6-0 5- 29 6- 41 5- 71 4-0 4-21 3- 02 4- 42 3-11 3-19 3- 31 4- 35 3-35 3- 11 7- 75 4- 79 6- 65 7- 04 6-48 1 in 4-54 1 The results at this hospital for the first nine months of 1876 were stiU more nnf avoui-able, the proportion of cures bemg only 1 m 8 31 .. ThisXXhiTrerse in the moi-tality after tracheotomy is attnbutedby SVoSTtS de Paris, 1876/No. 493), partly tl^e wogr^^re^ extension of the operation to more and ^ovehovele.sc^ses^dv^^ the more maUgnant character of the disease m Pans durmg recent years. LARYNGO-TRACHEAL DIPHTHERIA. 183 HOPITAL DES ENFANTS MALADES. . xe&rs. Dis- charged Cured. Operations Dead. f orVjroup . Left xmcured. Total. Proportion of Cures. X oO 1 . . , . 1 i. 17 0 31 1 in 2-21 lofj^ .... 1 R 10 0 61 1 ,, 3-38 LOOO , . . . q 52 0 61 1 ,, 6-77 1 OU^r .... 1 r 9Q 0 43 1 ,, 3-07 lOOO t . . , 1 9 .S4. 0 46 1 1' 3-83 -LU OO o 1 3-25 XOU f . . . . 1 fi J.U 0 70 1 '1 4-37 1 S'iS 7"? ( o 9 1 3-20 41 1 1 .'i 4 160 1 ' 3-90 94. 1 m Q o 1 9S 1 6"30 1861 .... 29 79 1 X 1 09 1 3"49 1862 .... 27 1 12 X X A g 1 " 5-37 1863 .... 46 XV/ 14-9 1 3'08 1864. 4.0 Q o I'JO X .J O Oii 1865 .... 40 86 1 /in 1 3-26 1866 .... 27 71 1 X 1 ^-74. 1867!". 15 57 4 76 1 „ 5-06 1868 26 36 0 62 1 ,, 2-38 1869.. .. 12 54 0 66 1 „ 5-50 1870.. .. 21 43 0 64 1 ,, 3-04 1871.... 16 27 0 43 1 ,, 2-67 1872.... 30 71 9 110 1 ,, 3-66 1873.... 26 79 .2 107 1 „ 4-11 1874.. .. 23 81 4 108 1 ,, 4-69 1875.... 38 130 13 181 1 ,, 4-76 614 1661 76 2351 1 in 3-82 At tlie Hospital for Sick Children in the twelve years 1864 to 1876, sixty cases of croup and diphtheria were operated on. Of these thirteen, or 21 '6 per cent., were successful. According to Krbnlein'si recent statistics at the Hospital in Berhn the percentage of cures after the operation was 30.2 This was the result of 567 operations performed between January 1, 1870, and July 30, 1876, in Professor Langenbeck's clinic. By selecting the best individual series of statistics, for the most part from private practice. Dr. Solis Cohen 3 has brought together 166 cases of tracheotomy in croup with 110 recoveries ! "Langenbeck Archiv.," Bd. xxi. hft. ii. ^ See also Hiiter : " Laryngotomie und Tracheotomie," Pitha- BiUroth's CMrurgie, vol. iii. part i. Nro. 6, p. 26, et seq. 3 " Croup in its Relation to Tracheotomy." Philadelphia, 1874. 184 DISEASES OF THE THROAT AND NOSE. Considering tlio enormous mortality of laryngeal diphtheria, even the most nnfavoiirahle figures prove that in such cases tracheotomy is not only justifiable, but that it is a positive duty. The chief questions to be considered in connection with the operation are what are the indications, and what is the best period for its performance 1 The cases most favourable for the operation are those m which the symptoms of general infection are slight or absent, and the strength of the patient is unimpaired. It is where the patient has still some vigour, where the pulse is strong and regidar, the powers of assimilation good, and the asphj^xia, though very marked, is not yet too advanced, that tracheotomy becomes most imperative. In such cases there can _ be no doubt that the operation has saved, and doubtless will still save, many thousands of lives. It is now generally admitted that tracheotomy shoidd be performed without delay, as soon as it has become clear that it is impossible to relieve the asphyxia by other means. It is clear that an early insertion of the caiiula gives the patient a much better chance of recovery than when there is a long delay ; and it is owing to the disregard of this fact that tracheotomy in diphtheria has in some°quarters acquired such an evil repute. For the descrip- tion of the operation, and the precautions which must be taken in performing it, I must refer the reader to the article on Tracheotomy, but I would Here caU attention to the extreme importance of endeavouring, immediately after the operation, to draw out any loose false membrane, either with the croup- brush or an aspirator accurately appUed to the mouth of the canula The after-treatment is very important, and the patient requires most assiduous attention for some days. The temperature and due moisture of the room must be carefully maintained, the tube must be constantly watched, and freed from secretions or pieces of ejected membrane, and the wound must receive dady attention At the same time the administration of food and stimulants must be the subject of the greatest care and recridarity, and antiseptic sprays shoidd be administered tM'OU-h the canula. The chief dangers to be feai-ed m the after-treatment of tracheotomy are extension of the exudation into the bronchi, occlusion of the tube, and fadm-e in the innervation of the lungs. The effects of extension of the membrane may in some cases be averted by removing the tube and extracting fragments of lymph froni the t^'achea v^h forceps, or with the croup-brush. Long strips of exudation, NASAL DIPHTHERIA. 185 und in rare cases almost entire casts of the Avmdpipe have been removed in this way. Occlusion of the tube is only to be prevented by placing the patient under the charge of a trust- Avorthy attendant, who wiU not faH in cases of emergency to remove the canula and free the passage. In the third stage tracheotomy remains the only hope oi saving the patient's hfe. If the operation has unfortunately not been performed in the second stage, the chance of success is very much diminished. The operation is not contra-mdicated, however, even when the apnosa is extreme, and the patient is apparently on the point of suffocation, provided only that the heart's power is still good. In some cases the patient has been saved by it when literally at the last gasp. Such instances, however, are quite exceptional. Some authorities have maintained that even in quite hopeless cases, where the patient is dying from dyspnoea, tracheotomy should be performed with the view of promoting the euthanasia. It is true that death from syncope or gradual exhaustion is much less painful than death from apncea, and it may be advisable to secure this substitution by a surgical opera- tion. But it is not in these cases that tracheotomy finds its really valuable application. When it is found on auscul- tation, that air enters one lung and does not penetrate the other, it is clear that the false membrane has extended down one bronchus, and tracheotomy is then much less likely to be of any use. In the same way, if extensive pneumonia has supervened the operation is likely to be of little benefit. Where the patient is akeady dying of cardiac failure or exhaustion, it is of course in vain to attempt to save life by the surgical operation. NASAL DIPHTHEEIA. In some epidemics of diphtheria the disease commences with nasal catarrh, and this phenomenon was so common in the epidemics witnessed by Bretonneau, that he regarded it as the common com-se of the disease. Further experience, however, has demonstrated that catarrh of the nose is far less usual than it was at one time supposed, and that true nasal diphtheria is generally due to the extension of the plastic infiammation from the pharynx. The disease commonly first shows its presence by an unhealthy brown ichorous discharge, wliich causes abrasion, and even ulceration, of the skin in the neighbourhood of the nostrils. Soon afterwards the parts 186 DISEASES OP THE THROAT AND NOSE. arc covered with false membrane which, can he seen extending through the nose. At other times the false membranes do not reach the external orifice, but, on using the speculum, a few scattered deposits of lymph can be perceived on the mucous membrane of the septum or the turbinated bones. The false membrane, however, is generally most abundant at the posterior nasal orifices. In this form of diphtheria it is especially necessary to endeavour to prevent the products of the disease from accu- mulating and putrefying in the nasal cavities, for experience has shown that, under such circumstances, they are extremely liable to be absorbed and to lead to secondary septic poison- ing. It is all-important, therefore, to keep the passages as clear as possible, by the use of astringent or solvent liquids. "With this object, weak solutions of alum, tannin, carbolic acid, permanganate of potash, or lactic acid, should be re- peatedly syringed over the affected parts. If epistaxis occurs,^ as it frequently does in nasal diphtheria, an astringent snuff or lotion is usuaUy sufficient to arrest it. Plugging the Jiares should, if possible, be aToided. The various features of Diphtheria are discussed ra slightly- greater detail in my recent work, entitled, "Diphtheria: its Nature and Treatment." ChurchiU, 1878. THE THROAT AFFECTIONS OF THE EEUPTIVE FEYEES.i (Scarlatina, Measles, and Small-Pox.) Latin Eq. — Morbi gutturis inter exanthemata (Febrem rubram, Morbillos, Variolam). French JJg.— Maladies de la gorge dans les fievres gruptives (Scarlatine, Eougeole, Variole). Oerman Eq. — Die symptomatischen Halsafiectionen bei den acuten Exanthemen (Scharlachfieber, Masern, Blattern). Italian Eq.—'LQ malattie deUa gola negli esantemi (Febbre scarlatina, Eosolia, Vajuolo). Definition. — Morhid phenomena manifested in the mucoua membrane and subjacent structures of the pharynx and larynx during the course of scarlatina, measles, and small-pox. 1 As the pharynx and larynx are so frequently affected together in the acute exanthemata, I have thought it better to treat all the local manifestations in this section. SCARLET FEVER. 187 Scarlet Fever. The mucous membrane of the jj7ia?7y?iaj is generally affected in scarlatina, and in some cases the pharyngeal enanthem appears to constitute the only local expression of the disease. Although the skin eruption of this fever often comes out on the second day, that is, the day after chilliness, vomiting, and headache have occurred, in most cases soreness of the throat is the first symptom complained of. In Scarlatina Simplex Little or no redness can be seen on examination, and there is only slight aching or stiffness, Avhich ceases in a day or two from the commencement of the attack. In Scarlatina Anginosa, great soreness of the throat is a marked feature of the disease. On inspecting the pharynx the whole of the mucous membrane is seen to be of a deep red or even violet hue, and as the fever develops considerable internal and external tumefaction of the tissues takes place. The tonsUs, and the sub-maxillary and parotid glands, are implicated in the morbid process, and in many cases all the structures of the neck become the seat of a violent phlegmonous inflammation, terminating at one or moTc parts in abscess. At this stage of the malady, viz., the third or fourth day of the attack, the mucous membrane of the pharynx generally becomes covered with a quantity of whitish pultaceous exudation. The subjacent epithelium is often partially destroyed, giving rise to shallow abra- sions ; but deep ulceration is very seldom present. In some cases resolution takes place at this stage ; the swelling becomes reduced, and the tissues soon regain their normal condition. In the worst instances, however, suppuration occurs in the cellular tissue or glands of the neck, and large abscesses form, which usually biirst externally, near the angle of the jaw, though sometimes they burrow downwards as far as the clavicle. After all the specific symptoms of the fever have disappeared, such cases frequently prove fatal from the exhaustion caused by copious and long-continued clischarge of pus. During the progress of this form of scarlet fever the disease sometimes extends to the larynx, when the voice is modiEed, and, if the epiglottis is much inflamed, deglutition becomes difficidt, and liquids regurgitate through the nose. Some difiiculty of breathing may also be present, but as Trousseau 1 observes, "scarlatina does not IDce the 1 " Clin. Med. de l'H6tel-Dieu." Paris, 1865, vol. i. p. 105. 188 DISEASES OF THE THROAT AND NOSE. larynx," and snffocation from oedema of the glottis is a rare issue of tlie complaint. In Scarlatina Malicjna the characteristic phenomenon is secondary diphtheria.^ In these cases the pharyngeal lesion is more tardy in its appearance, and the patient often seems at first to suffer from a mUd attack of the malady. Ahout the ninth day, when the eruption has disappeared and the feverish symptoms have abated, the disease attacks the pharynx, and in a few hoiu'S swelling takes place in the glands at the angle of the jaw. The tonsils and fauces are covered with diphtheritic exudation, a fetid sanious discharge proceeds from the nares, and the breath becomes tainted with a foid odour. Occasionally the morbid process extends to the larynx, and this has been noticed to occur more frequently in some epidemics than in others. Gupp - described an epidemic in Wiirtemberg in which, in the cn-eater number of cases, croupy symptoms appeared from the third to the fourth day of the iUness ; and in some cases death took place before the exanthem appeared. As m primary diphtheria, on separation of the lymph, idceration of the mucous membrane is often found. A characteristic specimen of ulceration (No. 36, Series W.) is contained in the Museum of St. Thomas's Hospital. The larynx, whicli was taken from an adult patient who died of scarlatina, has a very thin layer of lymph covering the entke mucous mem- brane, and the right arytenoid cartilage is laid bare by a large ulcer. Gangrene not unfrequently attacks the pharynx, larynx, and esophagus, the pulse becomes weak, the surface of the body is blanched and cold, coUapse supervenes, and the patient dies in a state of coma.3 in some cases large vessels are opened by the ulcerative process, and death occui-s from hsemorrhage. A somewhat rare complication of tlie mahgnant form of scarlet fever, "scarlatinal buboes, re- quires some mention. They are situated prmcipaUy in the -lands of the neck, which become suddenly inflamed about the tenth or twelfth day, and in five or six days a large abscess is formed. Sphacelus of the surroundmg ceUular 1 See Fuchs: "Historisclie Untersuchungeii iiber Angina Ma - Hg^ia ld ihr VerhaltnisBzuScliarlachfieberund Croup." Wurz- bSrg, 1828. 2 Eiihle : Op. cit. p. 243. • . ,r • 3 See Graves: "Clinical Lectures on the Practice of Medicine. Lect. xxii. Dublin, 1848. SCABLET FEVER. 189 tissue may take place, and Graves ^ and Trousseau 2 report cases in which the muscles of the neck were laid bare, and the carotids could he seen pulsating at the bottom of the wound. 1 • T Diagnosis. The recognition of the scarlatinal nature of the angina is principally based on the existence of the skin eruption diuing some period of the illness. The suddenness of the attack, the intensity of the accompanying fever, the deep red or violet tinge of the pharynx, and the occurrence at the same time of an epidemic of scarlet fever, all tend to assist in the diagnosis; but when the pathognomonic exanthem is absent some uncertainty must often remain as to the true nature of the malady. In such cases the subsequent development of dropsy and albumiauria occasionally sets any doubt at rest. Prognosis. — The local affection is itseK often a cause of death, and as the throat-manifestations of scarlet fever are the expression of the intensity of the general blood- poisoning, they furnish an important indication as regards the constitutional condition, fn scarlatiaa simplex the local affection is unattended with danger. Scarlatina anginosa probably results in death in about one-fourth of the persons attacked, whilst in the diphtheritic form about half the patients die.^ Treatment. — Local measures are of but little use in the treatment of the anginte of scarlet fever. Trousseau * advises the application of hydrochloric acid to the throat, when it presents a ptdtaceous or gangrenous aspect. The dilute acid has also been administered internally, on the supposition of its possessing a specific action against the general blood- poisoning. In severe cases a general tonic and analeptic treatment- must be adopted, whilst emollient gargles, hot, soothing inhalations, and warm poultices are the only local remedies that can be employed with advantage. The treat- ment of the plastic form of inflammation shoidd be such as is recommended for primary diphtheria, viz., the internal use and local application of the j)ersalts of iron, a highly nourish- ing diet, the free use of alcoholic stimulants well diluted, and the employment of antisej)tic sprays and solutions. The practitioner must always bear in mind that tracheotomy may be necessary. 1 Op. cit. vol. i. p. 345. " Loc. cit. p. 107. ' Sanne : Op. cit. p. 179. * Loc. cit. 190 DISEASES OF THE THROAT AND NOSE, Measles. The 2^^i(i'f!jngeal affection of measles is usually of slight importance, as in severe outbreaks of this fever the gravest lesions are manifested in the larynx, trachea, and bronchi In many cases no eruption takes place on the mucous membrane of the throat, whilst in the great majority of instances, although more or less redness can be seen on inspection of the pharynx, the patient does not complain of any soreness of the throat. The enanthem appears at about the same period of the fever as the exanthem, i.e. in the course of the third or fourth day. False membranes may become developed after the subsidence of the general pyrexia, and occasionally even gangrene of some portions of the pharyngeal tissues may occur.^ The laryngeal disease may be either a simple catarrh, or true diphtheria. The catarrhal form of laryngitis may occur before the exanthem, or a day or two after the rash has come out, but in some epidemics it develops when the eruption has almost disappeared.2 It is more common than the croupy form of disease, and though occasionally the inflammation runs high, it is seldom of any importance. The principal symptom is obstinate hoarseness. In a ntmiber of Professor Hebra's patients in the General Hospital at Vienna, in different stages of measles. Dr. Stofella^ found a highly injected condition of the mucous membrane of the larynx in abnost all the cases which he examined laryngoscopicaUy. " This variety of croup," observes Dr. West, " seldom begins until the eruption of measles is on the decline, or the_ process of desquamation has commenced. Its occurrence is most frequent from the third to the sixth day from the appearance of the eruption, but it oftener occurs at a later than at an earlier period."* Laryngeal diphtheria, or croup, is much more common than pharyngeal diphtheria. The prognosis is more unfavourable than in scarlatinal diphtheria, 80 per cent, of the cases terminating fatally. Treatment. — ISTo special treatment is required for the catarrhal affection, as spontaneous resolution takes place in seven or eight days. In the presence of false membrane, mortification, or collapse, the same measures must be adopted 1 See Barthez and EiUiet: "Traite des Maladies des Enfaats," "^^^^Bolm Konigsberger Medizin. Jahrbiiclier." 1852. 3 "Wien. Medizin. ■Wochenschrift," Nos. 18, 19, 20. 1862. ^ Op. cit. p. 448. SMALL-POX. 191 as recommended in tlie articles on diphtheria, croup, and putrid sore tlu'oat. Small-Pox. From the third to the sixth day of the eruption of variola the mucous membrane of the pharynx often becomes the seat of a crop of pustides similar to those on the skin. In quantity they correspond, to some extent, to the abundance of the exanthem, and in severe cases they cause considerable inflammation and tumefaction in the throat, together with great pain in swallowing. Pustular sore throat, as Trousseaiu^ remarks, is also often accompanied by ptyaHsm, whereas in scarlatina this symptom is almost always absent. Ulcerations of sufficient depth to lay bare the muscular tissues occasionally occur in. the malignant forms of confluent small-pox. The laryngeal affection may be a mUd papular or pustular eruption f f the mucous membrane, which causes little or no inconvenience, or it may be a diphtheritic process, which is often fatal. In the year 1863, through the courtesy of Mr. Marson, I was enabled to examine several patients in the Small-pox Hospital with the laryngoscope. In one patietit labouring under severe purpuric small-pox, I found ecchymotic spots on the under surface of the epiglottis and on the mucous membrane over the arytenoid cartilages. In a convalescent case there was a distinct pustule on the edge of the epiglottis ; in another instance, in which the entire body was covered with pustules, the larynx appeared perfectly healthy; and in another similar example there were no pustules, but there was marked con- gestion of the mucous membrane ; in another instance the upper surface of the epiglottis was covered with pustules. Trousseau ^ mentions the circumstances 6i three cases that came under his own observation, where death took place from suffocation. "Three patients," he observes, "had arrived at the eleventh day of a variola, which up to that time had pursued a normal course. Suddenly they were seized by a frightful attack of suffocation, which carried them aU off before sufficient time had elapsed for any one to come to their assistance. In one of these individuals, traces were found at the autopsy of inflammatory lesions of the larynx and pustules of smaU-pox below the glottis." In Loo. cit. p. 15, et seq. 8 Ibid. p. 16. 192 DISEASES OP THE THROAT AND NOSE. aiiotlier case ^ tlie post-mortem discovered oedema of the ary- epiglottic folds, with an abscess as large as a pigeon's egg between the (esophagus and larynx. Ruble, who witnessed a bad epidemic of small-pox in Greifswald, in 1856-57, and who made no less than fifty-four post-mortem exammations, observes,^ "Although I have seen here and there _ pustule- like elevations, I nevertheless consider the essential pecu- Harity of the laryngeal affection to be a croupous or diphtheritic inflammation." This author adds that as " out of the fifty-four cases there was not a single instance m which the larynx and windpipe were in a normal state, he cannot but attribute a certain proportion of the mor- tality to the laryngeal affection." Pathological examples of the diphtheritic complications of small-pox are to be found in the museums of St. Thomas's and St. Bartholomew's Hospitals and in other collections. In two instances I have known permanent paralysis of the adductor of a vocal cord foUow small-pox ; in both of these the larynx was affected at the time, and it is probable that the affection was of the diphtheritic character. Treatment.— Itv the milder class of cases, emollient gargles and weak astringent applications are useful. Suffocative attacks, dependent on oedema, must be met by scarification of the larynx, and in the worst cases by tracheotomy. In the diphtheritic form of disease treatment is almost useless, but the local remedies elsewhere recommended for primary diphtheria shoidd be adopted. THE THROAT AFFECTIOITS OF TYPHOID PEVER Latin Eq. — Morbi gutturis inter febrem entericam. French ^g.— Maladies de la gorge de la fievre typhoide. German iJ^?.— Halsaffectionen beim Abdominaltyphus. Italian Eq.—Le Malattie deUa gola neUa febbre tifoide. Definition.— r/ie throat afediom of typhoid fever are of tioo kinds— (a) a loio type of inflammation of the mucous membrane of the pharynx or larynx, leading in the latter situation to deep ulceration ; and {b) secondary diphtheria. The «7iar2/7ia; is not invariably affected in enteric fever the blood-poison more frequently provokmg an attack ot bronchitis or pneumonia. The mHdest and most frequent 1 Ibid. p. 20 ' Op- P- 247. THE THROAT AFFECTIONS OP TYPHOID FEVER. 193 form of pharyngeal lesion consists in a simple erythema of the mucous membrane of the mouth and fauces ; and subjectively the affection occasions but little inconvenience beyond a dryness of the throat, and slight soreness in swallowing. The parts gradually regain their natural condi- tion as the convalescence of the patient becomes established. Occasionally an herpetic eruption is seen on the mucous membrane of the pharynx and mouth, which is attended by considerable pain in deglutition. This affection, wMch is only an accidental complication, though more severe than the erythematous condition, Kke it also undergoes spontaneous resolution, without leaving any ill effects. Secondary diphtheria is accompanied by the physical ap- pearances and symptoms of the primary affection. ^ When this comphcation occurs in typhoid fever the prognosis is most unfavourable. Thus out of six cases mentioned by Oulmont,^ five terminated in death ; whilst Peter ^ states that aU the instances he has met with have proved fatal. In the larynx, as in the pharynx, both the inflammatory and the diphtherial affections are met with. The inflam- matory changes have, as Dr. Wilks ^' has pointed out, a great disposition to end in ulceration. According to Heinze,^ ou.t of 1 1 3 cases of typhoid fever examined at the Pathological Institution at Leipzig there were 13 cases of ulceration of the larynx. The ulceration sometimes involves a considerable surface, but it more frequently penetrates deeply and exposes the cartilages. It is generally at the posterior parts of the larynx, that is, at the under part in the prone position of a patient suffering from fever, that the disease is most fre- quently found ; and it is commonly thought to be caused, at least in part, by hypostatic influences. Frequently, how- ever, the sides of the epiglottis and the inter-arytenoid folds are ulcerated, and the disease in this situation has been attributed to friction. The cricoid cartilage is often seen to be denuded, and of a blackish grey colour ; and there is generally a corresponding discoloration of the opposite wall of the pharynx. There is some liability to cedema, but the ulcerative process more often appears to ^ See a paper entitled " Pharyngotyphus," iu Gunliurg's "Zeit- schrift." 1860, p. 156. 2 " Act. de la Soc. des Hop." 1859, 4e fasc. p. 30. ^ "Diet, des Sc. Med." Paris, 1864, vol. iv. p. 736. ■• "Trans. Path. Soo." vol. ix. p. 34, and vol. xi. p. 14. ' "Die Kehlkopfsschwindsucht." Leipzig, 1879. 0 194 DISEASES OF THE THROAT AND NOSE. originate in a typhous deposit — " laryngo-typlms being," as Kokitansky says, " the completion, as it were, of abdominal typhus." Toboldi states that the typhoid ulcer "com- mences in the mucous membrane as a circumscribed spot of congestion, -which soon becomes yellow and depressed, sinks into the tissues, and losing its epithelium, constitutes the decubital-ulcer. From absorption of tissue the small ulcers gradually attain the size of a bean, and generally have irre- gular discoloured edges." It is said that the cartilages often become independently diseased, ^'.e., become affected without the superjacent tissues being primarily involved. So many conditions of the larynx, however, are met mth which tend to the destruction of the cartilages that it seems unnecessary to resort to the theory that these structures are independently diseased. The further pathological changes wtU be found described under " Perichondritis of the Larynx." Secondary diphtheria is not uncommon in typhoid fever, but from the unconscious condition of the patient it is very often overlooked during Ufe, and only discovered at the post- mortem examination. Though it most frequently com- mences in the larynx, and is often confined to that part, the diminished supply of air causes little inconvenience, owing to the meduUa having, to a great extent, lost its sensibility to impressions. The obstruction to respiration is also less marked, from the fact of the disease, in most cases, attacking adults. Diphtheria rarely occurs before the end of the second week. The prognosis is very unfavourable, the prostrate condition of the patient preventing the use of antiseptic inhalations or local applications. Treatment. — In the catarrhal affection soothing inlialations are useful. In the diphtheritic affection little can be done in the way of treatment, and there remains only the operation of tracheotomy, which in these cases offers little prospect of _ success. Ttphus. The throat symptoms in typhus are similar to those met with in typhoid fever, but are much more rarely encountered. ' Tobold: " Laryngoscopie," &c. Berlin, 1874, p. 207, et seq. ERYSIPELAS OF THE PHARYNX AND LARYNX. 195 Intermittent Fever. Some practitioners make special mention of a sore throat connected witli intermittent fever. ^ The affection is said to be characterized by periodicity, and to arise from palustral blood-poisoning. The treatment consists in the administration of quinine, as in cases of ague, the symptoms of which are supposed to be only marked by the local phenomena in the throat. It is, however, by no means certain that an angina of this nature reaUy exists, the evidence forthcoming on the subject being both scanty and inconclusive. EEYSIPELAS OF THE PHAETNX A'NJ) LAEYNX. Latin Eq. — Erysipelas pharyngis et laryngis. French Eq. — ^Angine erysipelateuse. Qerman Eq. — Erysipelas des Schlundes und Kehlkopfs. Italian Eq. — Eisipola deUa faringe e della laringe. Definition. — Erysipelas of the mucous membrane of the phanjnx and larynx pathologically similar to the same malady when situated on the skin, and occurring either primarily or by extension from the face along the mucous tracts of the mouth, nose, or ear. History. — The existence of an erysipelatous affection of the mucous tracts inside the body was recognized as early as Hippocrates,^ who states : " When erysipelas extends from within outwards it is a favourable symptom, but when it removes to the internal surfaces it is a deadly one. The signs of this occurrence are— disaj)pearance of the external redness, with oppression on the chest, and difl&culty of breathing." Subsequent writers studied the phenomena of the retrocession of erysipelas with more tojDical accuracy, and Fabricius Acquapendente ^ refers to a case of metastasis — a phenomenon of doubtful occurrence. During the eighteenth century many authors gave descriptions of erysipelas of the pharynx with more or less precision ; and in 1757, Darluc,'^' in recounting the facts of an epidemic ' Peter: Loc. cit. ; also Desnos : "Diet, de Med. et de Chir. Prat." vol. ii. p. 472. 2 " Coacse Prenotiones," lib. II. cap. xiv. ' " Opera Chirargica." Pars Prior, lib. I. cap. viii. ■* "Journal de Med. et de Pharmacie." Juillet, 1757. 196 DISEASES OP THE THROAT AND NOSE. of erysipelas which occurred at CaiUan in 1750, expresses himself thus clearly : " In some cases the morbific matter extended to the throat, and caused difficulty of deglutition ; the voice became hoarse, with a species of suffocation, swelling in the muscles of the neck, and aU the symptoms of quinsy. Finally in 1862, Cornili almost exhausted the subject in an exceUent article containing cases which illustrate nearly every phase of the disease. Etiolony.—ni& causes of erysipelas of the pharynx or larynx are evidently those of the same disease when situated on the external parts of the body. Thus most cases seem to recognize an epidemic or an endemic influence, whilst a small p°roportion of the instances met with appear to occur sporadicaUy. The etiology with respect to age and sex has not hitherto been estabHshedby a sufficient mass of statistics but according to CornU,"- out of eighteen cases in which the pharynx was affected fifteen patients were under the age of thirty, and two-thirds of the cases were females. Symptoms.— When the disease is confined to the phwrynx the primary phenomena vary considerably in different cases, and also diverge widely from the first symptoms of simple tonsillar inflammation. Previously to the efflorescence ot erysipelas there is a weU-marked febrUe stage, m which the temperature sometimes rises as high as 104° Fahr. This initi- atory fever may last for three or four days before any soreness is felt in the throat or the characteristic redness appears on the skin In one class of cases— the majority— the pharyngeal disease occurs as an extension of a similar attack on the face, whUst in another the mucous membrane is hrst affected. Out of eighteen cases analyzed by Oomil, tiie erysipelas twice appeared simultaneously on the lace ana in the pharynx, the throat was the primary seat ot the disease seven times, and on nine occasions the skin was attacked first. The propagation of the nialady from the face to the pharynx and vice versa was observed to take place by different routes, viz. : (1) Most feequently by the Ups and mucous membrane of the mouth ; (2) by the nlsal fosL; (3) by the Eustachian ^^^^^ and the external auditory meatus, and (4) by the nasal fossse and the lachrymal sac and ducts to the conjuiic- tiva and eyelids. In none of the cases was there any metas- 1 " AroHv. Generales de Med." 1862, t. xLx. pp. 257, 443. 2 Ibid. p. 459 ^ Loc, cit. p. 449. ERYSIPELAS OF THE PHARYNX AND LARYNX. 197 tasis, but the disease spread by continuity of tissue, and tbe erysipelatous redness could be traced step by step along the paths indicated. In a case reported by Gull ^ tbe erysipelas spreading from the pharynx reached the face almost at the same time by the auditory and lachrymal channels. I have myself only met with foiu- undoubted cases of erysipelas of the pharynx. In three of these the disease spread from the pharynx to the face— twice by the nose, and once by the mouth and lips. In none of these cases was the diagnosis made out tiU the erysipelas reached the skin. In the other case the affection commenced in the auricle of the right ear and spread through the Eustachian tube to the uvula and left tonsil. The following were the sexes and ages of my patients r A man aged 58, and three women aged 47, 28, and 17. When the disease arrives at the pharynx the patient complains of pain and difficulty in deglutition. Swelling of the submaxillary and cervical glands is almost constantly pre- sent, and to such an extent, that in many cases, the patient can scarcely open his mouth. Stiffness of the jaw from this cause is sometimes complained of before anything can be seen on the skin or in the pharynx, and there is often con- siderable ptyabsm from implication of the parotid and sali- vary glands. The pharyngeal lesion may terminate in gangrene.^ In conjunction with so serious a phase of the disease, all the constitutional symptoms are much aggra- vated, and when mortification takes place the symptomatic fever assumes a low typhoid form, and there is a tendency to •death by collapse. On inspecting the pharynx the appearance of the mucous membrane, when affected with erysipelas, differs considerably according to the form of the disease wliich is pre- sent; the local phenomena are always very different from those of tonsillitis, but often cannot be distinguished from simple inflammation of the part. Cornil ^ makes three divisions of the malady, viz., (1) erysipelas with simple redness ; (2) erysipelas with phlyctenulse ; and (3) erysipelas terminating in gangrene. Thus it may be seen that erysipelas, when situated on the mucous membrane, tends to pursue a course exactly the same as when it affects the skin. In the first and mildest variety the pharynx presents a diffuse hue of deep purplish red, and has a shining aspect as if the mucous membrane were covered with a varnish. A variable amount 1 " Medical Gazette," 1849, on the " AUiances of Erysipelas." - Comil : Loc. cit. p. 453. 3 Ibid. p. 262. 198 DISEASES OF THE THROAT AND NOSE. of (Declematous swelling can also be generally perceived. The abnormal coloration extends over tlie veil of the palate and anterior surface of the uvula, over the piUars of the fauces and tonsils on both sides, and over the posterior wall of the pharynx. Whenbullee arise, aU the symptoms, both local and constitutional, are increased to an intensity which clearly in- dicates a severer expression of the disease. The vesicles vary in size from that of a miUet seed to a small nut, last but a few hours, and are fiUed with serum, pus, or even with blood, according to the observations of Cuu-e.^ It is oiten very difficult, except by collateral signs, to distinguish these buUse from herpes. On their disappearance they leave in their place a whitish yeUow patch of softened tissue, which is easily torn from the structures beneath by the act of swaUowing or coughing. Under these circumstances, mem- branous shreds may be seen hanging at various points from the sm-face of the pharynx. Thus the gi-eater part of the mucous membrane desquamates at the termination of such an attack. After this process has ceased, and all redness and pain have likewise disappeared, an injection of the superficial veins of the pharynx remains for a whHe, and constitutes for some time the last stage of the morbid action. Most cases terminate in resolution, but in a few instances the intensity of the inflammation has led to aancrrene of portions of the mucous membrane and the sub-mucous tissues. The occurrence of mortification can be readily recognized by the characteristic odom-, and by the dark, pultaceous appearance of the affected spots of the pharynx In the four cases which I have seen, recovery took place, though in one instance abscesses formed on the ala of the nose and in the cheek. . Ervsipelas most commonly reaches the larynx by extension from the pharynx, but the former organ may be P™^y affected, whHst the pharynx remains healthy. Mei" ^^^^ described the case of a woman, aged 35, who was admitted into one of the DubHn hospitals, on accoimt of enlaiged spleen and anasarca of the extremities. Unfortunately she was placed in the next bed to a pa lent convalescent fiom erysipelas, and in a few days she took hat complaint. The left eye first became swoUen and the pharynx inflamed, and 1 " Del'Ervsipele duPharynx Tlifese de Paris " 1864, No. 136 2 uS^Sons on the Sm-gical Pathology of the Larynx and Trachea." London, 1837, p. 104. ERYSIPELAS OP THE PHARYNX AND LARYNX. 199 the disease soon extended to tlie larynx. Tlie patient died comatose, from oedematous laryngitis, three days after the face was attacked. Sometimes the poison of erysipelas confines itself to the larynx, the skin being free from inflammation : at other times it passes from the larynx to the external parts. Cases of the former kind have been already placed on record by Cuire,^ and another one is now added (see page 201). In erysipelas of the head and neck there is gene- rally more or less congestion of the mucous membrane of the larynx. Occasionally, though less frequently, the affec- tion appears to originate in hospital-gangrene. ^ The symp- toms of the disease are difficulty in swallowing, hoarseness or loss of voice, and pain, which is increased on pressure externally. Dr. Semeleder ^ examined four cases of erysipelas of the face, with the laryngoscope, and in aU of them he found inflammatory redness and swelling of the epiglottis and larynx down to the vocal cords, though there was no dyspncea or dysphonia. The inflammatory symptoms in the larynx disappeared gradually with the desquamation of the skin ; and in one case a relapse of the cuticular affection was accomj)anied by a recurrence of laryngeal inflammation. Sometimes the disease is much more active and may result in an acute oedema, which rapidly tends towards a fatal termination. According to Peter * the malady may extend still further down the respiratory tract, and he states that in one instance he has seen it lead to "galloping consumption." Diagnosis. — The diagnosis of erysipelas of the pharynx and larynx cannot but remain doubtful except where it is accompanied by manifestations on the skin. Indispu- table as is the occurrence of erysipelas as an enanthem, there are no pathognomonic signs by which the disease can be recognized when confined to the mucous tracts. Pathology. — Erysipelas consists essentially in a local mani- festation on the skin or mucous tracts of a general blood- poisoning. "When situated internally, the morbid action is confined to the mucous membrane and sub-mucous tissues. The vessels of the part are loaded with effete elements, and the cellular tissue becomes infiltrated with unhealthy serum. "Where gangrene takes place the muscular fibres ' Op. cit. pp. 73-77. Ryland : " Diseases of the Larynx," p. 8. Loc. cit. ' "Diet, des Sciences Med." Paris, 1866, vol. iv. p. 723. 200 DISEASES OP THE THROAT AND NOSE. are softened and separated, but their substance is seldom destroyed. The course of the malady is too rapid for the process of sphacelus to extend deeply. In a case examined by Cornil,! ^^ere the larynx had become affected, the ary- epidottic folds were reduced to a mass of putrilarje, but the cartilages were left intact. In another case reported by the same author, gangrene of the palate and death having supervened, the autopsy revealed softening of aU the super- ficial structures of the pharynx. The mucous membrane was in several places reduced to a pulp, and the uvula was torn from the soft palate by a slight effort of traction. Prognosis —The local lesions occasioned by erysipelas are usuaUy subordinate to the severity of the general blood- poisonincr The intensity of the constitutional phenomena must guide us in giving a prognosis as to the probable termination of the attack. The dictum of Hippocrates, abeady referred to, has been confirmed by modei'n ob- servation. Thus in nine cases analyzed by Oornii- where the face was first attacked, seven deaths occurred, whereas in nine other instances where the enanthem pre- ceded the sldn eruption, seven recoveries took plape. ibe extension of erysipelas to the throat marks an increased intensity of the blood-poisoning, and in the majority ot cases the disease is not limited to the pharynx. It spreads do^vn the windpipe and oesophagus, and by giving rise to cedema ot the glottis, capillary bronchitis, and lesions of the ahmen- tarv canal, tends to a fatal issue. _ Treatment.-Bofh local and constitutional measm-es must be adopted in erysipelas of the thi-oat. As regards topical applications, I have seen benefit resiilt in two cases of pharyn- geal erysipelas from the insufflation twice dady of morphia U i) diluted with starch, whilst ice was constantly sucked and bromide of potassium given every four- hours. _ Hot soothing inlialations shoidd not be used as long as there is any chance of arresting the inflammation. Should the disease ter- minate in gangrefe, we must resort to antiseptic gargles of pe^^anganL of potash, chlorate of potash carbolic acid, &c whTt y cBdema of the glottis become developed, recou^e must be had to scarification of the larynx, and extreme Tases to tracheotomy. Perchloride of iron shoxdd be ad^ mastered internally, and if the vital l^^'^^^^f^ and ammonia, with a free aUowance of stimulants, will be 1 Loc. cit. p. 446. ' Loc. cit. p. 458. ERYSIPELAS OF THE PHARYNX AND LARYNX. 201 leqiiired The diet throughout the whole course of the disease should he of the most nutritive description. The foUowing case iUustrates the rare form of the disease in which the larynx is affected with erysipelas, whilst the phai'ynx and skin are unaffected : — ERYSIPELAS OE THE LARYNX; LARYNGOTOMY- DEATH. (Reported by Dr. Poetee, now of St. Louis.) » James S , aged 35, a strong, vigorous man was admitted into the London Hospital, January 19, 1874, for Capture of the right internal maUeoUus. For ten days the patient did very weU but then complained of pain in the throat and hoarseness On the foUowing day there was some dyspnoea, whilst the pam and hoarseness were more marked. His temperatui-e was 102°, pulse 132 and respira- tions 36 to the minute. A laryngoscopic examination on the succeedmg day discovered that the mucous membrane of the epiglottis and ot the arytenoid cartilages was acutely inflamed. The veotricular bands were so much swoUen as to cover the vocal cords. The patient was aphonic and the pain very intense. There was only very slight pharyngeal congestion. Inhalations of benzoin and mild astrmgent applications were used, and warm fomentations were apphed to the neck. Dr. MoreU Mackenzie saw the patient the next day, and foimd great tiraiefaction of the epiglottis, the mucous membrane of which was thickened and eroded. In consequence of the general swelling the vocal cords could scarcely be seen. The outer side of the neck was also somewhat tumefied. During that evening the pa,tient became rapidly worse. Pulse 160 ; respirations 44 to the minute and laboured ; temperature 103". "Laryngotomy became necessary early in the night. There was considerable hemorrhage, but the patient appeared very much un- proved by the operation. On the next morning, a dark flush was seen around the tracheal wound ; breathing was again difficult and dysphagia increased. There was a distinct fi-iction sound at the apex of the heart, and dulness at the bases of both lungs. The following day the patient was much worse, and the flush around the wound had increased in size and density. The dyspncea was more marked, and the dysphagia so great that no nourishment coidd be taken. Death ensued at ten o' clock that evening. [There were two cases of erysipelas in the same ward when the patient was admitted, and several of the attendants of the patients were subsequently attacked with sore throat.] " The autopsy showed that the heart was healthy, but the lungs were oedematous and of a dark colour. The larynx was greatly altered, the mucous membrane covering the epiglottis and the arytenoid cartUages beiag swoUen and ulcerated ; the lining membrane of the bronchi was bright-red. The traumatic affection of the leg showed no sign of erysipelas, the healing process appearing to have proceeded satisfactorily." 202 DISEASES OP THE THROAT AND NOSE. SECTION II.— THE LARYNX. ANATOMY OF THE LAEYNX. This complicated organ, which serves the double purpose of trans- mittrag' air and produoiag the voice, is sitiiated between the hyoid bone above and the trachea below, having behind it the pharynx, and on each side of it the great vessels and nerves of the neck. When the head is held upright and the larynx is at rest, the middle of the thyroid cartilage is opposite the body of the fifth cei-vical vertebra, the whole organ from the tip of the epiglottis to the lower border of the cricoid cartilage correspondiug to the thii-d, fourth, fifth, and sixth cervical vertebrae. But the position of the larynx is very far from constant, as it ascends and descends to a variable degree during respiration, phonation, and deglutition. Viewed from the front, the general external configuration of the larynx is as foUows :— Passing from above downwards there may be recognized by palpation, or iadeed by mere inspection iu thin persons : a protuberance (Pomum Adami) less prominent in females and boys before puberty, formed by the meeting iu the middle Une of the two alee of the thyroid cartilage ; above the laminaj is a deep notch, wlule below them is the depression for the crico-thyroid membrane, and agaia lower down the convexity of the cricoid cartUage. Laterally the quadrilateral laminse of the thyroid cartilage partially covered by the depressors of the hyoid bone may be made out, while below the lower border of the cricoid can be seen or felt a depression corresponding with the junction of that cartilage with the trachea. StiU lower there may be noticed, ia the middle Une, a slight pro- tuberance, the isthmus of the thyroid body, and on either side the lobes of this body, which vary considerably in their development, and in women, generally, give a more rounded form to the neck than in men. Below this crossing of the isthmus the trachea recedes between the converging stemo-cleido-mastoids, and finally disappears behind the suprasternal notch. The posterior surface of the laiynx constitutes the anteiior waU ot ^The^mper surface presents in front the Hgament, which unites the upper border of the thyroid cartUage with the hyoid bone, and the epiglottis with its five folds of mucous membrane ; further back, the superior aperture of the larynx, cordif oi-m m shape, descend- ing in an inclined plane with the larger extremity in front, and limited anteriorly by the epiglottis, lateraUy by the ary-epiglottac folds, and behind by the apices of the arytenoid cartilages and the upper border of the arytenoid muscle covered with mucous membrane. The inferior surface of the lai-ynx, corresponding with the lower edge of the cricoid cartUage, presents the ligament which unites that ANATOMY OF THE LARYNX. 203 cartUage with the first ring of the trachea, and the annular opening '"^Tlie'coTisidSon of the internal sm-face of the larynx is best deferred till the cartUaginous skeleton and other component parts have been described. _ • „ „j! „„,.4.;inr^oc The framework of the laiynx is composed of a series of caitilages, • nine in number, three being single and three m pairs The foi-mer are known as the thyi'oid and cricoid cartilages and the epiglottis. The latter are the arytenoids, and the cartilages of Wrisberg and San- toiini. There are also the sesamoid cartilages. The chief portions of the laryngeal framework are so articulated with one another by Ugaments as to be capable of a considerable mimber of movements, which are produced by means of muscles, the ftmction of which is to place the vocal cords in the proper position for phonation. Ibe internal sm-face of the cartilages, ligaments, joints, muscles, and vocal cords is covered by mucous membrane, and the entire apparatus is supplied with blood-vessels, lymphatics, and nerves. The thyroid cartilage is the largest portion of the laryngeal frame- work, and mav be described as consisting of two symmetrical four-sided plates, united' together in the middle line by an intermediate lamina. They include between them an angle of about 90°, and are somewhat obUquely inclined, so that their external surfaces look slightly down- wards. The inferior border of each plate is nearly horizontal, the posterior vertical, while the upper border is sinuous, being concave behind, and boldly convex in front. In the united plates this con- vexity leads to the formation of a deep notch, which serves for the attachment of the thyro-hyoid membrane. The posterior angles of each plate present two hook-shaped processes, named respectively the greater and lesser eomua. The former projects upwards and some- what inwards from the superior angle, and is connected by means of ligaments with the greater comu of the hyoid bone. The latter pro- jects downwards and somewhat forwards from the inferior angle, and presents on the inner surface of its exti-emity a facet for articulation with the cricoid cartUage. Placed immediately below the thyroid, and connected with it by means of the articulation just mentioned, is the cricoid cartilage. Its general f oi-m is that of a signet ring, the portion reijresenting the seal being placed posteriorly, while the thin and narrow portion corre- sponding to the ring, but which in this case takes up only a fourth of the whole circumference, is placed in front. Its inner surface is continuous with that of the trachea, being convex from above down- wards. Its external sui-face is plane, and presents in front a prominence between the attachments of the crico-thyroid muscles, posteriorly in the middle line a low vertical ridge, broader below than above, separating shallow depressions for the posterior crico- arytenoid muscles, and on each side an articular facet for the lesser comu of the thyroid cartUage. This facet, which is circular in form and concave, looks upwards, and is seated upon a wart-Uke prominence placed halfway between the upper and lower margins of the cartilage, and slightly anterior to the facet for the arytenoid. The upper border of the cartilage is horizontal posteriorly, but slopes rapidly downwards and forwards on each side, and ends in front in a broad but deep notch, to which is attached the crico-thyroid membrane. Just beyond its horizontal portion the upper border presents on each side a sloping oval facet for articulation with the corresponding arytenoid. The lower border is horizontal, and is 204 DISEASES OP THE THROAT AND NOBE. connected with the first ring of the trachea, sUghtly overlapping it ^'^The" ar^enoid cartilages are situated at the posterior part of the larynx and articulate with the cricoid, upon which they are very freely movable. They are pyramidal in shape with their apices flattened and curved towards the middle line and their bases obliquely sloped off so as to have an inward aspect 'Theyhave attached to them both the vocal cords and ventricular bands. Each cai-tilage presents for examination a posterior, an anterior or lateral surface, an eternal or median surface, and a base. The base, by means of ^^^^J cartnage aiticulates with the facet on the upper We^ljl^^ cricoid is concave from before backwards and presents two well-marked processes. One, the processus vocahs, is a prolongation of the angle fored at the junction of the base with the lateral and median sSces; it projects foi^ards into the larynx, and gives attachment t^he t^ue vocil cord. The other, the processus muscularis is con- nected with the external angle of the base, and gives attachment to the TDOsterior and lateral crico-arytenoid muscles. The smaUer cartUages may be briefly dismissed The cari^dages or cornicula of Santorini are two smaU masses of flbro- cartilage, about as large as miUet-seeds, and situated at the apex of the arytenoids The cirtUages of Wrisberg are two soft flbro -cartilaginous plates em-bedded m a group of mucous glands occupymg the ary- epiglottic fdds and are occasionally wanting. The sesamoid cartilages are very far from constant, but when present they occur m the form of two smaU elongated masses, attached by means of elastic fibres along the lateral border of each arytenoid. ; The epiglottis is a flbro-cartUage, which vanes somewhat m shape. When seen from behind it has a leaf -like form, with its stalk below aid expansion above. Eemoved from the phary^and pl^cedmth its anterior surface uppermost and stalk foremost, ithas very much the shape of an elongated saddle. As seen ^J^^.^^^^^'y^^ZTe^tLTll very much in appearance, according to its inclination m relation to the thyroid cartilage, and according to the extent its expanded portion cSls r^i^d on itself. In adults it is, in most cases almost vertic^ S in childi-en it is often obUquely li°ri.ontal-lower behmd than in fi-ont. It is attached by its lower margin to the mner SacTof the thyi-oid cartilage by means of 1^^^^^,^^:'^^:^ tissue and at this point forms a pro.iection, which m Me (seen irom nbove^ has a rounded form, and is called the cushion of the epiglottis SsTee upperZlin rises above the base of the tonpe, with whi^ It if loosely connected by means of three reduphcations of mucous li°::£tr^u-e jgiottic f om. '^^i^i^:t:ios^^^- ^iTrou^ We pits, -Mch cont%the gl^^^^^^^ ANATOMY OF THE LARYNX. 205 The Ug-aments of the larynx are : (1) the extrmsic, which ^^mte the laiynx ^^th other parts ; (2) the intrinsic, which uiute the difPerent narte of the larynx together; and 3 the mixed winch sei-ve both Lese lis TKxtrinsic are the thyx-o-hyoid and the onco-tvM. The thyi-o-hyoid Ugaments are thi-ee in number, ^iz-, the thyio- iyoid n^embLe in°the middle line and the thp-o-hyoid liga^^^^^^^ pi-oper on either side. The thyi-o-hyoid membrane is a rathei deh- cate^bandof elastic tissue, attached above to Posterior borde o^^^^^^^^^ body of the hyoid bone, and below to the margins of the supenoi thyi-oid notch.' It has in front a bni'sa, and it is separated from the epiglottis behind by a considerable cushion of fat. The thyro-hyoid Ugaments are cylindrical bands of fibro-elastic tissue uniting the Sweater comua of the thyroid cartHage with the extremities oi the hyoid bone. Between these Ugaments and the thyro-hyoid mem- brane the hyoid bone is connected with the thyi-oid cartilage by means of a thin layer of fibrous tissue. The crico-tracheal hgament is a fine membranous expansion, wHch extends from the lower border of the cricoid cartilage to the first ring of the trachea. The intiiasic Ugaments are the crico- thyroid, the cnco-aiytenoid, the superior thyro-arytenoid, and the inferior thyi-o-aiytenoid (vocal cords), whose Ugamentous use, however, is entii-ely subservient to their higher function. The crico-thyroid Ugament is a band of elastic membrane attached in front to the upper border of the cricoid and the lower border of the thyroid. The cnco-arytenoid Ugaments consist for the most part of scattered fibres, which assist Lq forming the capsule of the joint ; on the posterior surface of the cricoid cartUage, however, near its upper border and outer comer, the Ugamentous fibres are consoUdated into a strong band, which is inserted into the posterior and inner surface of the arytenoid cartilage near its base. The superior thyi-o-arytenoid Ugaments consist of only a few scattered fibres, w"hich are not con- tinuous, and though, to a great extent, constituting the ventricular bands, scarcely deserve the name of Ugaments; they are inserted anteriorly in the receding angle of the thyi-oid cartilage just above the insertion of the epiglottis. The inferior thyi-o-aiytenoid Ugaments are the most important structures in the larynx— the most essential featm-es of the organ. They are formed of strong bands of yeUow elastic tissue extending from the receding angle of the thyroid cartilage anteriorly, to the projecting angles at the base of the ary- tenoid cartilages (processus vocales). Examining them more in detail we find that each vocal cord is made up of fibres which are coUected into a single band only at their anterior exti-emity ; posteriorly they separate at an acute angle into three divisions ; the fii-st of these passes sUghtly upwards, and is inserted just behind the posterior extremity of the ventricle ; the second is attached to the processus vocaUs of the arytenoid cartilage and to the surface of the cartilage above the process, and the third, dividing into five or six smaU bundles, is attached to the lower part of the inner sui-face of the arytenoid cartilage, some of its fibres extending beneath the capside of the crico- arytenoid articulation and reaching the upper border of the cricoid cartilage. The vocal cords are covered with the mucous membrane of the larynx, and the fibres of the thyro-arytenoid muscle assist in forming a large proportion of their substance. When a vocal cord is drawn towards the median line, and a vertical section is made through it paraUel with the anterior sui-face of the spinal column, 206 DISEASES OP THE THROAT AND NOSE. it is seen to be tiiang-ular or prismatic. Two sides of the triangle are free, one directed upwards towards the ventricular band, the other dowwards and inwards towards the lower part of the opposite side of the trachea, and the third is the outer and attached edge. Sound is produced by the vibrations of the vocal cords when approximated. The only mixed Kgament is the epiglottic. It consists of an extriasic and intrinsic portion. The former is composed of a central glosso- epiglottic ligament uniting the anterior surface of the epi- glottis to the root of the tongue, and two hyo- epiglottic Ugaments passing outwards from the middle of the anterior surface of the epiglottis to the extremities of the body of the hyoid bone. The iatriasic portion or thyro-epiglottic ligament, is a finn but narrow fibrous band connecting the lower end of the epiglottis with the thyroid cai-tUage just below its notch. Between the cartilages and the mucous membrane of the larynx is a continuous layer of elastic fibrous tissue, which assists ia support- ino- the general structure of the larynx, and effectually adds to its resiliency. It is attached below to the cricoid cartilage, becomes blended with the crico-thyroid ligaments, and enters iato the formation of the vocal cords ; it Unes the ventricles of the larynx, and, thickening ao-aia, foi-ms the ventricular bands. It can be traced iato the ary- epiglottic folds, and after becoming firmly attached to the thyroid cartilage, foims the ary-epiglottic ligaments ; anteriorly it becomes blended with the thyro-epiglottic and glosso-epiglottic ligaments. In those portions of the laryngeal tube where there are no ligaments con- necting the moveable cartilages with one another, this fibro-elastic lamina is very thin, and can be with difficulty separated from the mucous membrane. . •The articulations of the larynx consist of the ciico-thyroid and crico- arytenoid articulations, and the fibrous connections between the arytenoids and the cartilages of Santoiini. The crico-thyroid articulation is composed of two true joints placed laterally, by means of which the lesser comua of the thyroid cartUage articulate with the circular facets on the cricoid. These joints are provided with articular cartUages, synovial membranes, and capsular hga- ments, and the movements they admit of are those of flexion and extension. The crico-arytenoid articulations consist of the two joints between the bases of the arytenoids and the facets on the upper border of the cricoid. Each joint is saddle-shaped, and is provided with a synovial membrane and a lax fibrous capsule, adimti;ing of a very extensive series of movements. The ari;iculation between each ary- tenoid and the con-esponding cartilage of Santonni coi^ists of a thin layer of fibro-elastic cartHage, which admits of very free movement in. every direction. £ j The muscles of the larynx may be divided for purposes of descrip- tion into three sets :-First, a weU-defined group on the anterior svx- face, connecting the cricoid cartUage mth the lower border of the thyi^oid, and termed the crico-thyi-oidei ; secondly, a pair of trianguiar muscles on the posterior sui-face of the cricoid cartilage, kno^sSi as the crico-arytenoidei postici or abductors of the vocal cords ; and, lastly, a group of smaUer muscles in the upper part of the laryW, arranged in a somewhat sphincter-like manner, and mclud- ing the thyro-ary-epiglottici, the axytenoideus, the thyi-o-arytenoidei extemi and intemi, and the crico -arytenoidei laterales or adductors. ANATOMY OF THE LABYNX. 207 All the laryngeal muscles, with the exception of the arytenoideus, occur in pairs. The crico-thyi-oideus muscle of each side may be easily shown, on dissection, to consist of two layers of fairly well-defkied muscle triangular in shape. In the supei-ficial layer, the fibres pass in a more or less vei-tical direction, and this portion has been termed on this account the crico-thyroideus rectus. In the deeper layer, the obKque arrangement of the fibres has caused the muscle to be known as the crico-thyroideus obHquus. The former is attached below to the anterior siu-f ace of the cricoid cartilage close to the middle hue, and spreading out as it ascends is inserted into the anterior third of the lower margia of the corresponding thyroid plate. The crico-thyroideus obliquus springs from the naiTow anterior surface of the cricoid by two heads which embrace the attachment of the crico-thyroideus rectus, and running obliquely upwards and back- wards is inserted into the posterior two-thii'ds of the lower margin of the coiTesponding thyroid plate, and the whole anterior border of the lesser horn. The crico- arytenoideus posticus is a flat triangular muscle, which arises from a shallow depression external to the median ridge on the posterior surface of the cricoid ; its fibres converge as they pass upwards and outwards, and are inserted into the posterior margin of the base of the corresponding aiytenoid cartilage, between the attach- ments of the arytenoideus and crico-arytenoideus lateralis. The third group of laryngeal muscles, the arrangement of which, as already remarked, bears some resemblance to a sphincter, may be divided into three layers. The outermost layer consists of the two thyro-ary-epiglottici ; the middle layer of the arytenoideus, the thyro- arytenoidei extemi, and the crico -arytenoidei laterales ; while the innermost layer consists of the two thyro- arytenoidei intemi. The thyro -ary-epiglotticus is a flat, narrow muscle, which, taking origin from the processus muscularis of the arytenoid cartilage, passes upwards and inwards, crosses its f eUow in the middle Une, and is inserted into the upper half of the lateral border of the arytenoid of the opposite vside, and the posterior border of the corresponding cartilage of Santo - rini. The lower fibres, after their attachment to the arytenoid, run forwards and slightly downwards, to be inserted into the thyroid car- tilage near its receding angle, while the fibres which are attached to the Santorinian cartilage are continued forwards and upwards into the ary-epiglottio fold, where they are joined by certain scattered fibres which arise from the thyroid cartilage, close to the anterior attach- ment of the muscle. The arytenoideus is a flat quadrilateral muscle attached to the lateral borders of the arytenoid cartilages, and running horizontally between these a,ttachments. Itis covered posteriorly by the thyi'o-ary-epiglottici, whUe in front it is in direct relation with the laryngeal mucous mem- brane. The thyro -aiytenoideus extemus usually consists of three portions, a lower, middle, and upper, the two latter being, however, occasionally absent. The lower portion may again be divided into two layers, an external and an internal. These arise side by side from the lower half of the internal surface of the thyroid cartilage, close to its receding angle, and from the fibrous expansion of the crico-thyroid ligament, and pass backwards to be inserted into the lateral border of the arytenoid cartilage. The inner portion runs in a horizontal direc- tion, and is attached to the lower half of this border, while the outer por- 208 DISEASES OF THE THROAT AND NOSE. tion passes obliquely upwards, to he attached to the upper half, some of its fibres passing to the cartilage of Wrisberg and the aiy-epiglottic fold. The middle portion of the thyi-o-ai-ytenoideus extemus takes ovishx from the angle of the thyroid cai-tHage close to its upper notch, and running obliquely downwards is inserted into the processus muscularisof theaiytenoidcartUage. The ^Pf^ P°^-*VT ^ ^l^^r ^ is also attached to this process, but its upper attachment is to the lateral border of the epiglottis, and it serves the same f unction, and Bomet mes takes the place oi the ascending fibres of the thyi;o-aiT-epiglotti^^^^^^^ The crico-arytenoideus lateralis arises from about the nuddle third of the upper border of the cricoid cartilage, and is inserted into the whole anterior margin of the base of the arytenoid, a few fibres occasionallv passing on to join the thyro-aiy-epiglotticus. The tCo-aVtenoideus intemu8 is a prism-shaped muscle, which arises from the angle of the thyroid cartUage just internal to the oricd^ of the thyro-arytenoideus externus, and mninng parallel to anfhi the substance of the vocal cord, is inserted mto the apex and upper and lower surfaces of the processus vocahs. On transverse sec- Hr^ H is seen to have three borders, the inner of wluch projects into Jhe vocal cord! while the two outer and the side of the mi^cle between them Ue upon the inner sui-face of the thyi-o-arytenoideus externus of the same side. , • i • i Lastlv there remains to be mentioned a muscle which is only _ex- centionaliy present, and which has been variously termed the cnco- th^ToMeuIposticus and the kerato-cricoideus. ^ ".^^ band of fibres which arises from the posterior surface of the cricoid cartilage just below the origin of the crico-arytenoideus posticus and paVsinI upwards and outwards is inserted into the postenor margin of the lesser comu of the thyroid cartilage. lie Tai-^ngeal muscles have two different fimctions to perform They haveT&st, to control the entrance into the larynx, openin^it and clSg it as circumstances may require ; and, secondly, to provide foi the mwer tension of the vocal cords during phona^^^^ These func- K however, are not entii-ely independent of each other. The muscles wMch naiTOW or close the enteance to the larynx mchide S the fiTst place, all those fibres which ascend to be attached to the SiSottis as^ weU as those which encircle the vestibule ; secondly X larjio-eai inlet is constricted by the aiytenoideus, which inproStes the arytenoid cartUagesto each other ; thirdly, the true tlotti^closed by the action of the thyro-aiytenoidei mterm and the Sl^^eSei Wales, both of which muscles are able to rotate ?he aSdd cartilages on their bases, and to appro™te theur in relation . ^^^^^^.^ ' gio^ produce in the vocal cords the Si^ee^rSl — ?; W production of notes of different ^^The arteries of the larynx are the superior laryngeal, the middle ANATOMY OF THE LAEYNX. 209 lai-yno-eal or crico-thyroid, and the inferior or posterior laryngeal. The superior laryngeal is in most cases derived from the supenor thy- roid, though it occasionaUy springs immediately from the external carotid. Eunning ahnost directly inwards between the greater horn of the hyoid bone and the upper border of the thyi-oid cartilage, it passes beneath the thyi-o-hyoid muscle and enters the larynx by perforating the thyro-hyoid membrane. Having sent an epiglottic branch up- wards, it passes obUquely downwards towards the middle of the lower border of the thyi-oid plate, supplying in its course the muscles and the mucous membrane in the upper part of the larynx. J ust before reaching the lower border of the thyroid cartHage it divides into two terminal branches, the larger of which anastomoses with the crico-thyi-oid, and the smaUer with the inferior lai-yngeal artery. The middle laryngeal or crico-thyi-oid artery arises from the superior thyroid nearly opposite the upper margin of the thyroid cartilage, and passes downwards and forwards, lying upon the thyro-pharyngeus and thyro-hyoid muscles. AiTived at the lower border of the thyroid cartilage it divides into two branches, the outer of which passes into the larynx below the inferior margin of that eartUage, and joins a branch of the superior larjmgeal, while the iixner division, unitiug with its fellow on the opposite side, perforates the crico-thyroid ligament and is dis- tributed to the laryngeal mucous membrane below the vocal cords. The inferior or posterior laryngeal artery is derived from a branch of the inferior thyi'oid, and passing upwards, together with the inferior laryngeal nerve, behind the crico-thyroid articulation, divides into two branches, one of which unites with a branch of the superior laryngeal, while the other is distributed to the crico-arytenoideus posticus muscle. The veins of the laiynx for the most part have a similar arrange- ment to that of the arteries, but their anastomoses vnth each other and with the veins of the thyi-oid glands, the root of the tongue and the trachea, are more numerous. They terminate in the interna] jugular. The lymphatics of the larynx are abundantly .supplied to the mucous membrane, but the cartilages, muscles, and ligaments are described as being entirely destitute of them. They are arranged in the form of a thick network, which closely foUows the arrangement of the mucous membrane, but the vessels are much narrower and the meshes much wider on the posterior surface of the epiglottis and along the true cords than in other parts of the laryngeal surface. The lymphatic capillaries of the larynx unite together to form lymphatic trunks at four different points, two of which are situated above the right and left ventricle respectively, and two below the cricoid cartilage, one on each side. The upper trunks receive the lymphatics from the epiglottis and from the upper and middle compartments of the larynx, and pass outwards between the greater comua of the hyoid bone and the upper border of the thyroid cartilage to join lymphatic glands. The lower trunks receive the lymphatics from the lower compartment of the larynx and terminate in lymphatic glands, situated on either side of the trachea. The nervous supply of the larynx is derived from the superior and inferior or recurrent laryngeal nerves. These are branches of the pneumogastric nerve, but there is considerable evidence to show that those fibres which are derived from the sijinal accessory nerve go, at least in part, to the laryngeal branches. The former P 210 DISEASES OF THE THBOAT AND NOSE. is for the most part a sensory nerve, but it supplies a motor branch to one group of muscles, the crico-thyi-oids. The remaining lar^&^al muscles are supplied from the infeiior laiyngeal, which is exclu- ""'A^uX^Z^^e.! nerve divides into two hranches opposite thJS-eZ comu oFthe hyoid bone. The external oi- smaUer branc^ desclnds over the thyi-o-phai-yngeus muscle 2°^^^ J^^^^^" of the thyroid plate, where it enters the crico-thyroid muscle. The LeS branch enters the larynx by perforating the thyro- hyoid mSrane, and passing inwards and ^l^^^tly backw^^^^^^ direetlv beneath the mucous membrane fonmng the floor ot the directly oeneatn numerous branches, which pass ;XUrl™s, "^^d do^rds. Some of these branches, the ?h™earrre distributed to the mucous membrane of the pharynx as low down as the lower border of the cricoid cartilage, as weU as to thT Xus pyrif ormis and outer layer of the ary-epiglottic fold Other bmnchL% laryngeal, supply the whole internal surface of %hTright recuiTent nerve is given o£E from the pneumogastric just below thf level of the commencement of the ascendmg por ion of the Jghl subSan artery, and, passing behind carotid a^^^^^ ascends between the trachea and oesophagus where it pierces the Merior conltrictor and enters the larynx close behind the cnco- S^oid articulation. In the first part of its course it is m proxinuty i o rtie anex of the right lung. The left recurrent nerve is giveji o£E by Se left pn uLogWc on a level with the lower border o he «rpW the aorta aSd winding round the transverse portion of the i ascendfto the larynx. "After entei-ing the larynx the nerves divide into branches which supply the If 37^&??1 "l^f^^f/ ^o^ions The inner surface of the larynx may be divided mto three portions, an uppX^ddle, and inferior, lying immediately one above another, and easHy defined by natural Hunts. f+i,.i„^^ isofasome- The uppermost of these spaces, or vestibule of the larynx, is o± asome wTTnt tiibiil ar form but, ow^g to its sloping upper aperture, of greater litSSnt tTak beinnd. ^It is bonded by the differe-t cai^i- Ses ^ted together by reduplications of mucous membrane. Its Sev Wdaryls identical with that of the laryiix above described wWle itsTwer margin is formed by the ventricular bands. The wMle "^J^°^''\"f, ^''^gtii.uie is foi-med by the epiglottis, and is anterior wall °* J^^f J^^f '^'^^^ its middle third, coiTesponding changes into a sort °^ .^^^'^^r^' .'^ ^ .^i ^aUs of the ^^^^-T^^'^whthti^r ^^^ ^SfV'Se^ot decrease in depth vestibule, which loi-m a luiiuw " , arv-enio-lottic baca- from before b-kw^^^^^^ posterior ments, and ^^^u leduplicataons g^^^orini, and those segments Ste^'^Tnlli^B^^^^^^^^ are attached the superior vocal ^or-fmPTif of the larynx is bounded above by an imaginary plane uniting _><= ventricles or pouches cords, while its lateral boiindaiies ^,l,^^*^\*;^°t;™''^,e aperture of Morgagni contained between these stiuctuies. xne y ANATOMY OF THE LARYNX. 211 between the ventiicwlar bands is more or less oval in shape, but wider behind than in front ; it slopes obliquely downwards and backwards, and tei-minates in the fissure separating the arytenoids. The inferior boundary of the cavity is constituted by the true vocal cords, the space between them being known as the lima glottidis. This space is in the adult about foiir-fifths of an inch in length, and, when the vocal cords are separated to their utmost, about half an inch across at its widest part. The glottis is larger in life than the cadaveric position of the vocal cords would indicate, the abductors being more powerful than the adductors. Dui-ing quick inspiration and expiration, a con- dition con-esponding with its greatest distension, its form is that of an isosceles triangle with its base posterior and its angles rounded off, but on forcible expiration, the edges of the lima approximate, and the vocal cords become parallel. The ventricle of Morgagni is oblong in shape, extending for about the length of the cords, and having externally the thyro-arytenoid muscle, and its mucous covering. Its external wall presents two crescentic folds of mucous membrane, between which is a deep fossa, and posteriorly a smaller funnel-shaped depression; while passing upwards to the vestibule, between the carti- lages of Santorini and Wrisberg, is a shallow channel, the filtrum. The inferior laryngeal space is bounded by the cricoid cartilage, the lower half of the angle of the thyroid cartilage, the vocal pro- cesses of the arytenoid cartilages, and the elastic and mucous struc- tures, which extend dovmwards from the free borders of the vocal cords ; laterally the walls of this space diverge below the cords to the calibre of the commencement of the trachea. The internal surface of the larynx is covered throughout by a mucous membrane, continuous above with that of the tongue arid pharynx and below with that of the trachea. In passing from the root of the tongue in front to the anterior siu-face of the epiglottis, it presents three well-marked reduplications— the glosso-epiglottio folds — one central and two lateral, including between them two shallow fossse. Laterally it descends from the pharynx over the palato-pharyngeus muscle, to be attached to the upper portion of the inner surface of the thyroid cartilage, whence it passes again upwards, external to the thyro-ary-epiglotticus, to form the outer layer of the ary-epiglottic fold. The fossa thus formed is termed the sinus pyriformis. In front of the vestibule the mucous membrane is firmly attached to the posterior surface of the epiglottis, and below that cartilage to the receding angle of the thyroid, fonning a well-marked furrow between the anterior attachments of the ventricular bands. The mucous membrane covering the lateral wall of the vestibule is smooth in frontj but as it approaches the middle line behind, it dips slightly down between the Wrisbergian and arytenoid cartilages to form the filtrum, a shallow furrow, which passes downwards and forwards, and ends in the ventricle of Morgagni. StiU further back the mucous membrane is firmly attached to the median siu-face of the arytenoid cartilage. Passing downwards, the mucous lining of the vestibule is continued over the yentricular band, to which it is somewhat loosely attached, into the ventricle of the larynx. It covers the whole internal surface of this cavity, presenting the folds and fossse which have been described above, and passing again inwards attaches itself firmly to the sharp edge of the true cord. Between the cords poste- riorly, it loosely covers the anterior surface of the arytenoideus 212 DISEASES OP THE THROAT AND NOSE. muscle, being thrown into vertical folds on the contraction of this muscle and the residting approximation of the arytenoids Below the vocal cords the mucous membrane is attached rather closely to the inner sm-face of the cricoid cartUage, whence it is contmued downwards to form the tracheal lining. ^ , . i The laiTHgeal mucous membrane presents both tesselated and ciliated epitheUum. The latter has the more general distribution ?he tesselated ceUs being confined to the upper and ---ier ^j^j; ^ces of the epio-lottis, to a naiTOW zone ust withm the upper aperture of the ™, and to the projecting edges of the true cords which are co^d by a band of large, flattened, angular cells. In these parts thl eSheUal layer is in direct contact with the mucosa, but, else- where S rests upon a transparent homogeneous basement or hmitaiy memb -ane, a structure which plays an important part in the patho- of laryngeal diphtheria. It occasionaUy presents itself as an entirelv indSendent layer, which can be separated without difficidty torn the subjacent structures, but as a rule it is mtimately connected S the fibrous tissue of the mucosa. Accordmg to Luschka, how- ler a homogeneous basement membrane only e^sts in the vicmity of the true cords, and even here it contains both fibiillp and colonies of ceuX- elements. The mucosa itself consists of a connective tissue of delicate fibrils enclosing numerous prohferatmg masses of ceUs These ceUs, which are finely granular, and consist of a distmpt nucleus enclosed in a thin layer of protoplasm, vary considerably m si^e and number, being least numerous in the mucmis covering of the tme cords. Luschka Regards them as the real matrix of the laryngeal StheS, and assigns them an important share m aU mflammatoiy afiections of the larynx. The presence of these prohferatmg ceU- masses is the chief c^stinguishing- mark between the ^^<^'^^-^\ J^^ next layer of the mucous membrane, the submucosa. The latter consists^of mimerous wavy elastic fibiiU^B, which run more or less paraUel to the surface and are, as a riile, longer and somewhat coarser than the fibres of the mucosa. They enclose here and there sSe-shaped ceUs, which consist of an elongated, finely -granulax ^Cleus and a thin layer of protoplasm, prolonged at one end ^to a wavy, tail-like process. The laryngeal mucous membrane ^Psents verV few pajill£e, and these only m certam hmited ?JSons X upon the anterior surface of the epiglottis and thT'edge of the true cords. Throughout the larynx along t^^^^^^'^p^vj.ane is richly provided with glands, which ovei bu^c jj mrtilao-p in the neighbourhood ot tiie cam- iTw wSbig 0? tS^^^^^^^ bands,;and thi-oughout the w^s n/+L vScles with the exception of the upper sm-faces of the ^ Jrr^V Thevare also irre|ularly distributed over the posterior oTtt li;^ e'speciaUy in thJ neighbourhood of the cnco- "'toT^StheS^^^^^^ anatomical student is refen^d to the foUow- For have been largely laid under obhgation by the mg works which ^^7;^ ^^^^j^^-f Menschen," Tiibingen, 1871,; R^Y^^HanSuch £r syst^atischen Anatomie des Menschen," Henle: -n-anaDucn uci o " Manual of Hiunan and Zweite f Strieker Ti-anslatedbyHenrj^ iZTS:B^ ^t%iSl^ Society's Ti-ans. London. 1872. THE LABYNGOSCOPB, 213 THE LAEYNGOSCOPE AND ITS ACCESSORY APPARATUS. History of its Invention.— There is no trace of a laryngoscope before the middle of the eighteenth century, biit in the year 1743 M. LeATet, a distragaiished French accoucheur, whose higlily in- ventive genius had led him to contrive siu-gical instruments of almost eveiy description, occupied liimself in discovering means, whereby polypoid growths in the nostrils, throat, ears, and other parts, could be tied by Ugatui-es.^ It is imnecessary to describe here the various ingenious instruments which he invented for the purpose, but it may be observed that in using them he employed a speculum which differed from the various specula oris then in use., _ It consisted mainly of a plate of polished metal {plague polie), which " reflected the kmiinous rays in. the direction of the tumour," and at the same time received the image of the tumour on its reflecting sm-face. About the year 1804, a certain Dr. Bozzini, of Frankfort-on-the- Maiae, caused a gi'eat sensation throughout Geimany, witli his inven- tion for illuminating the various canals of the body. He had made known his ideas a few years previously, but it was not till 1807^ Fig. 11. — BozzEJi's LAHTNGEAii Speculum {after Sufeland). In the drawing from which this is taken, the mirrors are directed upwards, as they would be when employed in rhinoscopy. that he published a work on the subject. Bozzini's invention consisted of two essential parts : Fii-st, a kind of lantern ; and, secondly, a number of hollow metal tubes {specula) for intro- duciag into the various canals of the body. The lantern was a vase-shaped apparatus made of tin, in the centre of which was a smaU wax candle. In the side of the lantern there were two round holes, a larger and a smaller one, opposite each other. To the smaller one an eye-piece was fi:sed, to the larger the speculum was fitted. The flame of the candle was situated just below the level of these two apertures. The mouth of the speculimi— a tube of polished tin or silver — was always of the same size ; but the diameter of the tube beyond its orifice varied according to the canal into which it had to be introduced. The apparatus was about thirteen inches high, two inches fi-om before I l^'Mercure de France." 1743, p. 2,434. • iJer Lichtleiter, oder Beschreibung einer einfaohen Vorrichtung', und ihrer Anwendun^ zur Erleuchtung innerer Hoblen und Zwischenraume des lebendea WeTma? 1807 "^""^ P^ipp Bozzini, der Medizin und Chirurgie Doctor. 214 DISEASES OF THE THROAT AND NOSE. backwards, and rather more than thi-ee from side to side. In employing reflected light, Bozzini had the speculum divided by a vertical partition, so that there were, in fact, two canals and two mirrors. One of these miii'ors was intended to convey the Ught, the other to receive the image. tat In the year 1825,' M. Cagniard de Latour, the successor of Savai-t at the French Academy of Sciences, and Uke him, an earnest investi- gator of the physiology of the voice, made an unsuccessful endeavoui- to examine the larynx duiing life. In the year 1827^- Dr. Senn, of Geneva, " had a httle nurror con- structed for introduction to the back of the phaiynx ; with it he tried to see the upper part of the larynx-the glottis ; but he gave up its use on accovmt of the small size of the instrument. In the year 1829,^ Dr. Benjamin Guy Babington exhibited at the Hmiterian Society of London an instrument closely resembhng the larvno-oscope now in use. Two mirrors were employed, one smaller, f or receivi£g the laryngeal image, the other larger for concentratmg the solar rays on the fi?st. The patient sat with his back to the sun, and whilst the iUuminating mii-ror* (a common hand looking- o-las's) was held with the left hand, the laryngeal mirror-a glass one coated with quicksilver-was introduced with the right. In the year 1832,5 Dr. Bennati, of Pans, used an instriunent made by one of his patients named Selligue. It consisted of a double - tubed speculum; one tube of which seiwed to cai-ry the bght to the glottis, and the other to bring back to the eye the image of the glottas reflected in the mirror, placed at the guttural extremity of the mstru- ^^^'the year 1838,6 m. Baumes exhibited at the Medical Society of Lyons a mirror about the size of a two-franc piece, which he described as being very useful for examining the posterior nares and ^'''S'the year 1840,' Listen, in treating of cedematous tumoui-s which obstruct the larynx, observed as follows: "The existence of this swemng may often be ascertained by a careful examination with the ^oS^,"andl view of the parts may sometimes be obtained by means o?a sneculum-such a glass as is used by dentists on a long stalk, pre^oudy^pedinhot'water, introduced with its reflectmg surface downwards, and carried well into the fauces. ■ . •j„„ Xthe year 1844,« Dr. Warden, of Edinburgh, conceived the idea of emploS a prism of flint glass f or obtainmg a view of the ^^'tnthe vear 1844," Mr. Avery, of London, invented a laryngoscope in prLcJple veiy slniiar to that now in use. The reflector was attached i836-3S, ^■f?' Practical S™.; 18^^^^^^ illustrations, of a Totally f.U%efalso "Lond^f • -KTnd Kl^'ta'cduction to the Art of Larj^- gosc^p'^y^^-b^S;': yS^Lo^^^^^^ The instrun^ent is figured o. page 2* of my work on " The Laryngoscope.' THE LARYNGOSCOPE. 215 to a frontal-TDad and was retained in its place by two springs which passed over the operator's head to the occipital protuberance, where there was a counter-pad There were two defects, how- ever in AveiT's apparatus : the one was that the lai-yngeal Sor (histtad of being fixed to a slender shank) was placed at r eni ot a sptvdunT; the other, t^^^* -^^-^ °* J^f *t reflector for receiving the rays from a lamp placed on the table or elsewhere, Aveiy used his large circular mu-ror for the pmpose of increasing the luiiinous power of a candle held near the patient's "'S'the laryngoscope of Bozzini and Avery the lamp and the reflec- tor are combined, whilst in the modem instrument they are separate The laryngeal miiTor of Bozzini and Avery was placed at the end ot a speculu^ : Czermak's was a modification of the dentist s muror. Mr: Avery's invention was not placed on record till some tune after the modern laryngoscope had come into use. , j • In the year 1854,i "the idea of employing mirrors for studying the interior of the larynx during singing " occurred to Signor Manuel Garcia. He had often thought of it before, but, beheving it imprac- ticable, had never attempted to realize the idea. The efforts of Signor Garcia, who was quite imaware that any sinular attempts had previously been made iu the same direction, were crowned with success, and the following year he presented a paper to the Royal Society of London, entitled "Physiological Observations on the Human Voice."^ This paper contained an admii-able account of the action of the vocal cords during inspiration and vocalization ; some very important remarks on the production of sound iu the larynx ; and some valuable reflections on the foi-mation of chest and fal- setto notes. Signor Garcia' s laryngoscopic iuvestigations were aH made on himself ; indeed, he was the fii'st person who conceived the idea of an autoscopic examination. His method consisted ia intro- ducing a little miiTor, fixed to a long stem, suitably bent, to the top of the pharynx. He directed that the person experimented upon should turn towards the sun, so that the luminous rays falling on the little mirror should be reflected into the larynx ;3 but he added in a foot-note, that "if the observer experiments on liimself, he ought, by means of a second mirror, to receive the rays of the sun, and direct them on the miixor which is placed against the uvula." Signor Garcia' s communication to the Royal Society, though causing little stir at the time, was destiued to create a new era in the physiology and pathology of the larynx. Treated with apathy, if not with iucredulity, in England, his paper passed into the hands of Dr. Tiirck, of "Vienna, and soon effected a revolution in the investigation and treatment of laryngeal disease. In the year 1857,* during the summer months, Professor Tiirck, 1 "Notice sur I'Invention du Laryngoscope," par Paulin Richarcl. Paris, 1861 ; see M. Garcia's letter to Dr. Larrey, dated May 4, 1860 (page 12 in Eiohard's pamphlet). 2 "Proe. Eoyal Society of London," vol. vii. No. 13, 1855; "Philosoph. Maga- zine and Journal of Science," vol. x. p. 218; and"Gaz. Hebdom. de M^d. et Cbii-." Nov. 16, 1865, No. 46. It is worthy of note that Garcia never really followed this plan, hut, in point of fact, always used a second muTor for throwing the solar rays on to the laiyn- geal mirror. In the mirror which he used as a reflector, he also saw the auto- scopic image. ' " Zeitscbrift der Ges. der Aerzte za Wien." April 26, 1858. 216 DISEASES OF THE THROAT AND NOSE. of Vienna, endeavoured to employ the laryngeal mirror in the wards of the General Hospital. In the month of November of the same year.i Professor Czeimak, of Pesth, commenced to work with one of Dr. Tiirck's laryngeal mirrors, and in a short time he overcame all difficulties. Artificial light was substituted for the uncertain rays of the sun, the large ophthal- moscopic mirror of Ruete was used for concentrating the luminous rays, and mirrors were made of different sizes. Thus it was that G-arcia's re-invention of the laiyngeal mii-ror led Czei-mak to create the art of laryngoscopy. The references, in nearly every section of this work, to medical practitioners in Europe and America, will afEord evidence as to the great development of this new department of practical medicine in recent times. The Laryngoscope is essentially the laryngeal mirror, but for practical purposes it may be said to consist of two parts : Fia. 12. — The Laeyngeai Mieeoe. A Diagram showing the exact pizes of the reflecting surface of the mirrors Nos. 1, 2, and 3. B. The mirror and holder (half-size) seen in profile. 1st, a small mirror fixed to a long slender shank, which is introduced to the back of the throat ; and 2ndly, an apparatus or arrangement for throwing a strong hght (solar or artificial) on to the small mirror. The Laryngeal Mirror— may be made of polished K'Wien.Medizin. Wochenschrift." March, 1858 ; and '' Pbysiolog Unters. mit Garcia's KehlkoTDfspiegel," mit iu. Tafeln. Sitzber. der. k.k. Akademie wL. Wienf y™ 9 riril', bd. xxix. p. 557. (Afterwai-ds reprinted in a separate form.) THE LAEYNGOSCOPE. 217 Steel, or of glass backed witli amalgam. Thougli, on theo- retical grounds, the steel mirrors give the more perfect image, tliey so readily become tarnished and rusty from the least moisture, are so immediately spoilt by accidental contact with the medicated solutions nsed m treating laryn- creal disease, and so soon become scratched ni cleaning, that they are not found convenient in practice. The g ass mirror is crenerally mounted in German silver; for though the niettl is too favom-able to the rapid cooHng of the mirror, and the consequent deposit of moisture upon it, it is more easy to fix the shank of the instrument to a frame of metai than to any other substance of inferior conducting power. The mirrors should not be more than one-twentieth ot an inch in thickness. The reflecting surface of the laryngeal mirror may vary from half an inch to an inch and a quarter in diameter. It is weU to be provided with at least three muTors, varying m size between the dimensions specified. The largest sized mirror is called No. 1, the middle sized one No. 2, and the smallest No. 3. j <. For ordinary purposes, a No. 2 mirror will be found most convenient. It may be of square, circular, or oval shape. The circular mirrors canse least irritation, except when enlarged tonsils are present, in which case the oval mirrors are most suitable. The shanlc of the mirror should be of Ger- man silver ; it ought to be about four inches in length, and one-tenth of an inch in thickness, and should be soldered to the back of the mirror, so that the latter forms with it ' an angle of about 120 deg. The handle should be about three inches in length, and rather more than a quarter of an inch m thickness. The shank or stem of the mirror is some- times, for the sake of portability, made to slide into a hoUow wooden handle, and is fixed there by a scrcAv, as is shown in the annexed drawing (Fig. 12, B). The little screw referred to is, however, apt to get loose, and if the stem is made moveable, it should be screwed into the handle — the end of the stem itself forming the screw. It is better, perhaps, to have the stem immoveably fixed to the handle, as firmness is thereby ensured. Arrangements for Refleding the Light.— Yoy throwing a light on to the laryngeal mirror, and thus into the larynx, it will be foimd most convenient to employ a circular mirror about three inches and a half in diameter, with a small •218 DISEASES OF THE THEOAT AND NOSE. liole in the centre.^ When artificial light or diffused day light is employed, the mirror should be slightly concave, and have a focal distance of about fourteen inches ; but when solar light is made use of, the surface of the mirror should be plane. The mirror may be attached in some way to the operator's head, or fixed to a hori^iontal arm, which is connected with the body of the lamp (Tobold).3 The former plan is by far the most convenient, and the mirror may be worn either opposite one of the eyes (Czermak),^ in front of the nose and mouth (Bruns),* or on the forehead (rournie,^ Johnson," &c.). Of these positions, the first is, on theoretical grounds, the most per- fect ; the last the easiest in practice. The plan of looking throuo-h the hole of the reflector offers the great advantage of Fig. 13.— ReFLECTOE attached to SPECTACLE-rEAME, FEOM WHICH THE UPPEE HAIVES OP THE EIMS HAVE BEEN EEMOVED. At the back of the reflector (iJ) is a smaU cup, mto which a baU coDneeted mto the spectacle-frame fits. A ring is screwed over the baU, and the joint is thus formed at J. entirely protecting the observer's eyes from the glare of the 1 The reflector should not merely be left unsilvered in the centre, but should be actuaUy perforated ; othei-wise the glass makes a shght focal inequaUty between the two eyes. Laryngoscopes, made m every respect according to my dii-ections, are sold by Messrs. Mayer and Meltzer, 7 1 , Great Portland Street.^ 2 "Laryngoscopie," &o. Berhn, 18/4, p. 19. 3 Loc. cit. . * "Die Laryngoscopie." Tiibmgen, 1873. 5 Loc. cit. 1, lor. « "Lectures on the Laryngoscope. lbt)4. THE LARYNGOSCOPE. 219 licrht ; for whilst the luminous rays necessarily fall obliquely on the mirror, and therefore do not reach the pupil of the eye immediately behind it, the other eye is also within the shadow of the reflector. It is only m the first position moreover, that the observer can look through the hole in the reflector; if, therefore, either of the other methods is practised, the reflector need not be perforated. The reflector may be attached to the operator's head, either by a spectacle-frame (Semeleder),i or by a frontal band, as re- commended by Kjamer, and flrst employed by Bruns.- The spectacle-frame, with the upper halves of the nm removed (as seen in Fig. 13), is the arrangement Avhich I have found most convenient. In either case the mirror should be connected with its support by a ball-and-socket joint. The hole in the centre of the reflector should be oblong, and when placed in front of the eye, its long diameter should correspond with the long diameter of the eye. A hole of this shape allows for the varying distance between the nose and eyes in difi'erent people, and for the varying position of the centre of the reflector, in 14. — The Authoe's Eack-Movement Lamp. The chimney of the lamp is made of metal, a round hole being left where the lens fits in. its different degrees of inclination. Practitioners who labour under defective vision will find it convenient to have suitable glasses fitted to the spectacle frame of the frontal reflector. ^ " Die Laryngoscopie," &c. Wien, 1863, p. 13. 2 Loc. cit. p. '22. 220 DISEASES OP THE THROAT AND NOSE, Illumination.— Anj lamp that gives a bnglit steady liglit answers the purpose perfectly well. Many ot the most valuable observations have been made with a com- mon " moderator." An argand gas-burner will be lound very convenient, especially if constructed on the reading- lamp principle, so that it can be fixed at different heights. My rack-movement laryngoscopic lamp, which readily admits of perpendicular and horizontal movement, will be found to greatly facilitate the management of the hght._ Its action shown in Fi^r. 14. The power of the light is uicreased by Fig. 15. — Tttr CLnacAi Lamp. Tt, thP illustration, the lamp is seen hooked on to the horizontal har of a bed ; th?dotteKs ZV the position of the base when the lamp is sta^dmg on a table. a lens placed in front of the flame. My lamp is now used iii nearly every hospital in this country where laryngoscopy is systematically employed. _ . ^ i j Tor use at the bedside, where gas is not at hand, my new clinical lamp will be found very serviceable. It has the same action as the rack-movement lamp, but parafldn is used fr iUumination instead of gas. It makes a very useful lamp for the consulting-room. By reference to the wood- cut (Fi- 15), it will be seen that the base of the apparatus can be°hooked on to the bar of a bed, and that the per- pendicular stem rotates, so as to adapt itself to this position. THE LARYNGOSCOPE. 221 On the other hand, when in use on the table, the stem can be easily adapted to the upright position, by means of the screw at its foot. i _n t. t n In the various lamps or lanterns recommended by dif- ferent foreign laryngoscopists (Tobold,i Moura-Bouroumou,^ &c &c.), the arrangement of lenses in each of them is only applicable to the particular lamp for which it was contrived. This serious objection to the various kinds of illuminating apparatus hitherto in vogue, led me to contrive a light-concentrator of more extensive appli- cation. It not only gives a very brilliant light, but is at the same time much smaller, and therefore much more Fig. 16. — The Light-Concenteatoe. In the drawing, the concentrator is fixed on to a candle by-means of two arms (a). In using a lamp, the arms embrace the chimney : s, screw for tightening the arms ; i, one of the cork knobs for taking hold of the concentrator when hot. portable than any of those hitherto in use, and it can be employed with any kind of lamp, or even a candle. It consists of a small metal cylinder, three and a half inches long, and two and a half in diameter. This is closed at one end, and at the other there is a plano-convex lens, the plane J Loc. cit. p. 19. - "Traite pratique de laryngoscopie," &c. Paris, 1864. 222 DISEASES OP THE THROAT AND NOSE. surface of which is next the flame. The lens is two and a half inches in diameter, and is about one-third of a sphere. In the upper and under sui-faces of the cylinder (opposite each other) are two round apertures, two inches and a quarter in diameter. These holes are not equidistant from the two ends of the tube, but so near to the closed ex- tremity that a line passing perpendicularly through their centres would be about two inches and a half from the plane surface of the lens, and rays of light pass through m compara- tively parallel directions. At the lower part of the tube are two semi-circular arms, which, by means of a screw at the side, can be made to grasp tightly the largest lamp-chmmey,_an ordinary candle, or even the narrow stem of a single gas jet. The practitioner, therefore, who, in visiting patients, carries my lic^ht-concentrator, can always feel certain of being able to iUuminate the fauces. The apparatus is passed over the chimney till the centre of the lens is opposite the most brilHant' part of the flame, and then, by a few turns of the screw, the concentrator is fixed in position. \\ hen a candle is employed, the flame is in the centre of the tube. In the side of the tube near the lens are two ivory knobs covered with cork, which enable the practitioner to hold the concentrator and remove it from the lamp, even when it is extremely hot. For the consulting-room the hght-concentrator mav be most advantageously employed either mth an argand aas-burner, a paraffine, moderator, or reading lamp. The latter kind of lamp, with an argand gas-burner, wiU be found convenient, though my rack-movement laryngoscope lamp is the best that can be employed. , , . , - The H-ht of a candle, strengthened by this concenkatoi, will be found to equal that given by an ordmary lamp, men the practitioner has only a centre gaseher at his coni- manT the ligM-concentrator should be applied to the only St whichisU-hted; and as it is not generaUy possible to 3tu a ^seMciUy low down to make tl- ™^-n in the ordinary way, under these circumstances both patient nS^^r— iTS'Lcribed, I have had a L ^both but n the latter the metal cylinder is only same m both but m ^ ^^^^ ^ ^.^^^^^ . witMt tSs lamp, ^vhich measures only four inches from THE LARYNGOSCOPE. 223 its foot to the top of the chimney, is like a little vial, and has a metal screw stopper, so that it can he carried ahout with safety. It has heen already ohserved that the employment of a reflector is not absolutely necessary for throwing a light on to the laryngeal mirror. The solar rays, or diffused light, on a bright day, may be concentrated on the laryngeal mirror. In the former case, the surface of the reflector must be plane ; in the latter, the usual concave mirror may be used. The patient should sit -with his back turned obliquely to the ■window, and the practitioner opposite him. The sunlight in this way passes over the patient's shoulder to the reflector, and is thence projected on to the laryngeal mirror. In other respects the examination is conducted in the same way as when artificial light is used. When the observer does not make use of a reflector, the rays of hght must be thrown fi'om a lamp directly into the patient's mouth, or else the luminous rays must be pro- j"ected from a light in less close proximity by a lens placed in front of the flame. In using an ordinary lamjD for direct illumination, either a common plano- convex lens may be used, or a large glass globe about six inches in diameter, filled with water. The latter kind of concentrator (the so-called Schusterkugel) was first re- commended by Tiirck,! and afterwards adopted by Stoerk ; but, whilst the former soon abandoned its use in favour of the reflector, the latter still employs it almost mvariably. This apparatus has been further improved by Dr. Walker, of Peterborough. It gives a brilliant light, which is most in- tense at about twenty inches from the globe. As it is quite impossible to carry this enormous glass globe about, its use is necessarily confined to the practitioner's consulting-room. A much more convenient plan is that adopted by several of the French physicians, which may be thus described : A lamp provided with a lens is placed on a table so narrow, that the laryngeal mirror can be used by the practitioner on a patient sitting on the opposite side of the table. A shade screens the light from the observer's eyes, whose face, in this mode of examination, is close to the lamp. In applying remedies, the lamp is between the arms of the practitioner, who, as it were, embraces it. Dr. Fauvel, of Paris, uses a table about three feet long and one foot broad, in thi-ee > ''Zeitsckrift der GeseUschaft der Aerzte," Nro 8, 1859, imd " AUgein. Wien. Med. Zeitung," Nfo 15, 1859. 224 DISEASES OF THE THROAT AND NOSE. leaves: tke centre leaf, on which a moderator lamp rests, can be screwed up and down to different heights for different patients. Dr. Krishaberi employs a simple round table ot small dimensions. t -ui. • -u i-o,. For direct illumination the oxy-hydrogen hme hght is by fa the best that has yet been invented, and is especiaUy adapted for demonstrations of cases to a number of persons Not only is the light superb, but the mode of dlummatmg is much less fatiguing to the operator when a large number of cases have to be seen, and the heat if not ac ually less, is less felt on account of its being further removed from hun.^ Macinifving Instruments.— V anxious instruments have been invented f or increasing the size of the laryngeal image, but thev are of no use in the treatment of disease. As early as 1859 Dr Wertheim, of Vienna, recommended concave larvnc^eal mirrors for this pui-pose; and later. Dr. Turck,- callino- attention to the fact that the larjoigeal image is made-up of a number of parts at different distances sug- aested the use of a smaU telescope which he had fitted to his illuminating apparatus. Finally, Voltolmi* made some further improvements in the apparatus. Mlorometers.-Fox measuring the exact size of different parts of the larynx, and for estimating distances, Merkel, of Leipzig, and Mandl," of Paris, have suggested the plan ot havini a scale scratched on the laryngeal ^^jo/- Semeleder 7 objected to this mode of measuring, as it takes so mS away from the reflecting surface of the mm-oi-^ and Zmmended that the scale should be di;awn on the frame of the mirror. Though these scales might, pei-haps, be advantageously employed for physiological investigations, thpv are of no use to the medical practitioner. Za™« Chcdrs, Head-rests, ^c.-Most people, when they are Sout to have the thi-oat examined, lean back ni the chair throw up the head, and open the mouth. Tins attitude! h^^^^^ laryngoscopy, where . ..Diet. Encyclop. J- S~,^,^S^Ss LtS^^^^ ^. A ifi c, posterior commissure of the ' wal cor™ right vocal cord ; I, left vocal cord, with a wart on it. image (ac in A, Fig. 17), and -the posterior commissure, pc, which, in reality, is farthest from the observer, becomes LARYNGOSCOPY. 229 A nearest in the image.^ The symmetrical character of the image, which makes it impossible to judge of right and left, and this antero-posterior inversion which actually takes place, often lead people to form erroneous opinions concerning the two sides of the larynx. The lateral relation of parts in the image must now be considered. The mirror being placed above and hehind the laryngeal apertiu-e, the rays of light proceeding from the larynx pass directly upwards and backwards, and the patient's right vocal cord is seen on the left side of the mirror, and the left vocal cord on the right side of the mirror (just as the patient's right hand is opposite the ob- server's left, and liis left hand opposite the observer's right). In the annexed cut (Fig. 20), a wart is seen on the left vocal cord of the larynx (B) ; this is opposite the observer's right hand, and it appears on the same side in the image (A). In consequence, however, of the antero-posterior inversion which takes place, as explained in the last paragraph, if the fact that the representation of the larynx (A) is an image is not borne in mind, it wordd lead to the deceptive idea that the wart was on the right vocal cord. In examining a laryngo- scopic drawing, a person must not make his own larynx the mental standard of comparison as regards right and left, but must recollect that the picture represents an image formed on a mirror held obliquely above and rather hehind the larynx of another person. In making a laryngoscopic examination there are three stages. First Stage. — The patient should sit upright, facing the observer, with ids head inclined very slightly backwards. The observer's eyes shoiild be about one foot distant from the patient's mouth, and a lamp burning with a strong clear light should be placed on a table at the side of the patient, the flame of the lamp being on a level wth the patient's eyes. The observer should now put on the spectacle-frame with the reflector attached, and directing the patient to open his mouth widely, should endeavour to throw a disk of light on to the fauces, so that the centre of the disk corresponds with the base of the uvula. If the observer has much trouble in projecting the light on to the fauces, he will find it convenient to incline the ' This is in accordance with the fundamental optical law : - That if a diverging pencil of Ught fall upon a plane reflecting surface, the focus of the reflected pencil wiU be at the same distance from the Hurface as that of the incident pencU, but on the opposite side of it. 230 DISEASES OF THE THROAT AND NOSE. reflector at a suitable angle before putting on the spectacle- frame. This may be done as follows : Taking the spectacle- frame in the hand, with the mirror attached, so that the central aperture in it would come opposite to the pupil of the operator's right eye, and fixing the joint so that the back of the mirror is parallel with the spectacle-frame, the outer edge of the reflector should be pushed rather more than a Fig. 21.— Laryngoscopy— Thied Stage, SHOWiNa Position of Pbaotitionee and Patient. quarter of an inch forwards or backwards, according as the lamp is on the right or left side of the patient. If the observer has chosen his position and placed the lamp as directed, on LARYNGOSCOPY. 231 putting on the spectacle-frame, a beautiful luminous disk wiU \ \ Fig. 22.— Diaqeam SHOWING THE ANGLES OF INCIDENCE AND Reflexion in Oedinaey, and Infea- glottic, LAEYNQOSooFr. A. Side view of mirror, when properly introduced. It is seen to push back the uvula towards the posterior nares. B. Side view of infra-glottic mirror. C. Left vocal cord. appear at the back of the throat. "When direct light is used. 232 DISEASES OF THE THROAT AND NOSE. the first stage is much simplified, as the patient has only to sit opposite the lens of the lamp, as described at page 223. Second Stage.— T\\q patient shoidd be directed to put out his tongue, and the observer should hold the pro- truded organ gently but firmly between the finger and thumb of his left hand, the thumb being above and the finger below. To prevent the tongue slippmg, the ob- server's hand should be previously enveloped in a small Tig 23 —The Position of the Hand aitd Mieeoe, when the LATTEE has BEEN PEOPEELY INTEODUCED FOE OBTAINXNG A VIEW OF THE LaEYNX. soft cloth or towel, and he should be carefid to keep his finger rather above the level of the teeth, in order that the frsenum may not be torn. The position of the practitioner and patient is shown in Fig. 21. In cases that are likely to require local treatment, the patient shoidd be taught to hold out his own tongue, so that the operator may be able to introduce the mirror with his left hand, whilst_with the right he appUes the remedy to the affected part. ^. , . „ , . Tiiird Stage —When the observer has practised the first two stages, he should take a smaU laryngeal mirror about half an inch in diameter, and after warming its reflected surface foi a few seconds over the chimney of the lamp (to prevent the moistui-e of the expired air being condensed on it), should introduce it to the back of the throat. In holding a mirroi over a lamp, the Httle glass is fii-st covered ^vith a film ot LARYNGOSCOrY. 233 moisture, which quickly clears away. Directly the glass is clear, it is the right temperatiu-e— neither too hot nor too cold —to be introduced, Before introducing the mirror, how- ever, lest it should he accidentally too hot, the practitioner . should test its temperature hy placing it on the hack of his hand. Supposing that the various steps already described have been followed, and that there is a steady disk of light on the base of the uvula, the laryngeal mirror should ■ now be introduced ; but no attempt should ever be made unless perfect illumination has first been effected. _ To pass the mirror to the back of the throat with as little annoyance as possible to the patient, the following method should be adopted : The handle of the mirror should be held lilve a pen in the right hand, and quickly introduced to the back of the tliroat, its face being directed downwards, and kept as far as possible from the tongue in the median hne of the mouth (Fig. 23). The posterior surface of the mirror should rest on the uvula, which should be j)ushed rather up- wards and backwards, towards the posterior nares (Fig. 22). When the mirror has thus been introduced without irritating the fauces, the observer should raise his hand slightly and direct it outwards towards the corner of the mouth. This rotatory movement, which alters the inclination of the mirror, and turns its face more towards the perpendicular (whilst the hand is thereby kept entirely out of the line of vision), should be effected rather slowly, so that it can be arrested directly the larynx comes into view. After introducing the mirror, the observer can, if he chooses, steady it, by resting the third and fourth fingers against the patient's cheek. The exact angle which the mirror should bear to the laryngeal aperture must depend on a number of chcumstances, such as the degree of flexion backwards of the patient's head ; the particular angle which the plane of the laryngeal aperture bears to the horizon in the case undergoing inspection ; and on the direction which the ray must take to reach the observer's eye — that is to say, on the position of the ob- server (Fig. 23). The practitioner should learn to introduce the mirror with either hand, for by so doing any false ideas concerning a supposed asymmetrical condition will be at once corrected ; and Avhilst, for the purpose of diagnosis, it is very desirable to be able to use either hand, in the application of remedies to the larynx, ambidexterity is absolutely essential. Beginners, in their anxiety to get a good view, often give rise to faucial irritation, by keeping the mirror too 234 DISEASES OF THE THROAT AJJD NOSE. long in the patient's mouth ; but one of the commonest mistakes made by those unpractised in the use of the laryn- goscope, consists in introducing the laryngeal mirror before the disk of light has been steadily concentrated on the base of the uvula. The imperfect illumination causes the operator to touch the back of the throat in several places before it is put on the right spot. Again, beginners often lose the light, even after they have thrown the rays in the first instance m the proper direction ; under these circumstances, instead of withdrawing the laryngeal mirror and redirecting the light on to the centre of the fauces, as the skiUed laryngoscopist would do, the beginner moves his head (which supports the frontal mirror) in°the hope of thus being able to throw the light to the right place, the laryngeal mirror being kept in the mean- time in the patient's throat, where it is certain to cause irritation. This is a fatal error. The practitioner should recollect that when an act of retching has once taken place, it is afterwards often impossible to get a good view of the larynx at tlie same sitting. Moreover, the act of retching always causes considerable temporary congestion of the laryn- geal mucous membrane, and thus is apt to lead the inex- perienced to very erroneous conclusions. It is, therefore, better to introduce the mirror any number of times, keeping it in the throat only for a few seconds each time, than to let it remain longer, and thus limit the examination to one in- spection. The novice must be careful to avoid touching the toncrue with the mirror, for this procedure irritates the throat and spoHs the reflecting surface of the mirror for the tune. This can generally be avoided by keeping the back of the mirror in close proximity to, but not letting it touch, the palate. In some people, however, the uvula is in actual contact with the back of the tongue, and as in mspiration or vocalization the uvula is raised, such patients should be directed to inspire deeply, or to produce some vocal sound (such as "ah," "eh," "oh," &c.) ; the mirror can then be easUy slipped in between the uvula and the tongue All violence or even roughness must be carefully avoided, the tongue must be held out most gently and the laryngeal miiTOr placed very Hghtly on the uvula. Comphcated in- • struments for holding the mouth open almost invariably lead to failure. . , , n i . Special DifflculUes.-T\ie difficulties solely dependent on the practitioner's want of dexterity have been already con- sidered, but a few words must be devoted to those in part due LAEYNGOSOOPY. 235 to tlie patient. The obstacle may be either undue irritability of the fauces, a peculiar action of the tongue, an abnormal size of the tonsUs, or a pendent condition of the epiglottis. As regards faucial irritability, it is to be observed that though this condition sometimes exists of itself, it is far more often caused by the clumsiness or inexperience of the prac- titioner. Most patients can be examined with facility at the first sitting, and only a small proportion require any training. With timid patients— especially women— on first using the laryngoscope, it is well to place the mirror for a second on the back part of the palate, without being too particidar about seeing anything. By introducing the mirror once or twice in this way, the patient's confidence is secured, and a more fruitfid examination may afterwards be made. For reducing an unusually irritable condition of the fauces, we may have recourse to several expedients, in order to enable the patient to tolerate the introduction of the laryngeal muTor. Bromide of potassium is generally supposed to have the power of producing anaesthesia of the pharynx, but the effects of this drug are too uncertain to meet the wants of the laryngoscopist. The method of frequently painting the mucous membrane with chloroform, ether, or solution of morphia recommended by Tiirck ^ and Schroetter,^ is tedious and attended with the danger of producing serious general narcotism. Von Bruns ^ advises that the pharynx shoidd be sprayed with a solution of tannin, or pencilled with a mixture of tannin and glycerine. When, however, the practitioner requires to make an immediate inspection of the larynx, his object may almost always be accomplished by directing the patient to suck small pieces of ice con- tinuously for fifteen or twenty minutes. This remedy rarely, if ever, fails to blunt for a short time the ordinary sensi- tiveness of the mucous membrane. In cases, where it is necessary to carry out a prolonged local treatment of the larynx, as in the removal of growths, the patient may be directed to practise on himself daily with the laryngeal mirror. The conformation of parts occasionally causes some difficulty. Thus, when the tongue is drawn out, it sometimes forms an arched prominence behind, which causes trouble in introducing 1 " Klimk der KraiiMieiten des Kehlkopfs." Wien, 1866, p. 561, et aeq. - " Jahrestericht," &c. (op. cit.), 1870, p. 34. ^ " Die Laryngosk. u. die Laryngoak. Chirurgie." Tiibingen, 1865, p. 63. 236 DISEASES OF THE THROAT AND NOSE. the mirror, and difficulty in seeing it when in situ. This position of the tongue is due to reflex action, and wiU be hest avoided hy puUing the tongue less forward than usual, keeping it level with the mouth (that is to say, not holdmg it down towards the chin), and by cautioning the patient not to strain. Enlarcred tonsils sometimes embarrass the operator, in this condition a small oval mirror should he used. An unusually large or pendent epiglottis causes a more serious impediment to laryngoscopy. When the valve is very larcre, it sometimes shuts out the view of the larynx; biit the same result is more often caused by unusual length or relaxation of the glosso-epiglottic ligaments. In the production of high (falsetto) notes, the epiglottis is generally raised, and this also happens when a person laughs ; the observer will, therefore, do well to take advantage of these physiological facts. In a certain number of cases, however, the epiglottis remains obstinately pendent. For elevating the valve in these cases, various instruments have been invented, but they seldom prove of any service. Some of the German laryngoscopists recommend that a thread sJiouia be passed with a curved needle through the epiglottis An assistant, standing behind the patient, draws the thread over the patient's face and head, or the opposite end ol tHe thread may be tied round one of the patient's ears. Aiost of the instruments hitherto invented, however, cause so much irritation that they cannot often be employed M-ith advantage.i when the epiglottis covers the larynx in the manner described, the laryngeal mirror should be mteoduced lower in the fauces, and more perpendicularly than is usually suitable. In almost aU cases the arytenoid carti- lages, sm-mounted by the capitula Santorini, can be seen and from them we can judge with tolerable certainty as to Se mobmtyof the vocal cords; the state of the mucous membrane of the larynx in other ^^^^^^^^^^^^^^^^ safely inferred from the condition of that which covers the arytenoid cartilages. I ^PPTiirok- "Klinikder KeMkopfskrankheiten." Wien, 1866, p. 551 efseq ToboldT^Laryngoscopie.'- Berlin 1874, p. 449, et s^. ; Oeriet Deutsches Archi/^ur kUn. ^-^:^^^?\^^^ff 4 ; and my work on the "Laryngoscope. Third Edition, p. AUTO-LABYNGOSCOPY. 237 Auto-Laryngoscopy. Those wlio desire to acquire dexterity in introducing the mirror at their own expense, rather than that of their patients, and those who wish to demonstrate their larynx to others, shoidd learn to employ the laryngoscope on them- selves. When auto-laryngoscopy is practised, it is requisite that, besides the circular reflector and laryngeal mirror, another mirror should be used : this must be placed in such a position that the image reflected in it from the throat-mirror can be seen by the autoscopist. For practising auto-laryngoscopy, Professor Czermak ^ contrived a special apparatvis. It has a large reflector and quadrilateral mirror, each supported on perpendicular bars. These mirrors are fixed about a foot apart, and both can be turned in almost any direction, and fixed at any height. In using this apparatus, the observer should sit at a table with the quadrilateral mirror a few inches in front of his mouth, and the reflector a foot further back, the upper edge of the square mirror being level with the lower edge of the reflector behind it. The flame of the lamp should be near, but a little behind and to the side of, the quadrilateral mirror. The observer now throws the light into his fauces with the reflector, introduces the warmed laryngeal mirror, and sees the image in the quadrilateral glass. People facing the demonstrator can see the image in the laryngeal mirror, and those behind him in the one which he looks at. Por those who wish to make accurate physiological observations, this is the best method of practising auto-laryngoscopy. Those who object to purchase a special apparatus can use the ordinary reflector for auto-laryngoscopy. In this case, aU that is requisite is a perpendicular telescope-bar, capable of being made about a foot and a half in length, and having a broad firm base : at the top of the bar is a small projecting ball, which fits into the socket at the back of the ordinary reflector. The reflector is placed on a table, at about eighteen inches from the observer, between whom and the reflector there must be a small toilet mirror or hand-glass. In other respects, the examination must be conducted as already described. A simpler method of practising auto-laryngoscopy is that recommended by Dr. George Johnson.- The observer puts on ^ Loc. cit. pp. I and 28 (with illustrcation). « Loc. cit. 238 DiaEASES OP the throat and nose. Ms ordinary reflector, as though he were going to examine a patient, and sits facing a toUet mirror. A lamp is placed on one side of the observer, in a line with the mirror, or slightly behind it, and by manipulating the reflector the observer now throws the light on to the image of his fauces, as seen in the toilet-glass. He then introduces the laryngeal mirror into his throat, and the image of the larynx formed on it is seen in the toilet-glass, both by the demonstrator and by the persons standing behind him. _ In practising auto- laryngoscopy in this manner, the practitioner has to manage the li^ht in the same way as in examining patients, and he thus fearns to overcome one of the difficulties of laryngo- sco-DV The only disadvantage of this method, as compared with that of Czermak, is that, by it, the rays of Ught undergo an additional reflexion before they reach the larynx, and thus the image is not quite so distinct. Infra-glottic Laryngoscopy. Where tracheotomy has been performed, and a fenestrated canula is worn, a very minute mirror may be introduced through the tube with its face directed upwards ; or the canula may be removed, and the mirror passed into_ the wound (Fig. 22, p. 231). In this way the observer obtains a view of the larynx from below. >r j- „x- i ■ This method was fii-st suggested by Dr. Neudorfer,i 1858, and was first carried out by Professor Czermak- in the foUowing year. Since then, various observers have exa- mined patients in this way, and I have myself often had the opportunity of employing the mirror from below. Some investing observations made by a medical man on himself have been recorded by Dr. Semeleder.^ This mode of examining the larynx, though of very limited application, is vXble, because it generally happens in cases where a 2n2 i worn, and air is inspired mainly through the trachea, haUhe epiglottis does not rise up, but remains pendent, m nspiration fin post-tracheotoiny cases, also, it often happens that the epi-lottis is bonnd down ov.^r the larynx by old ckatrices,Xd consequently ordinary laryngoscopy is useless. It is weU to remark that the vocal cords, when observed from below have a reddish colour, and do not present the pecuhar wS'appearance which is seen when the laryngeal mirror is placed on the uvula. ,o,o xr « « Wiener Med. •Wochenschrilt. 185J, JNro ii. i^oc. o p THE LARYNGEAL IMAGE. 239 THE LARYNGEAL IMAGE. Tlie rationale of the formation of the image having akeady been explained (page 227), the special description of its indi- vidual parts will he now undertaken. In some cases, on introducing the laryngeal mirror, only the epiglottis may be visible, with perhaps just the tips of the capitula Santorini at the posterior part ; whilst in others, the entire length of the vocal cords, the ventricular bands, the small cartilages of Wrisberg and Santorini, a portion of the cricoid cartilage, the rings of the trachea, and perhaps even the bifurcation of the bronchi below it, can be seen with perfect distinctness. The view varies in different cases between these two extremes. The epiglottis varies very much in appearance in different individuals. In some cases it is broad, whilst in others it is extremely narrow ; in some only the upper surface can be seen, in others, where the epiglottis is drawn tightly to the tongue, only the under surface is visible. In the centre of the free edge is a slight notch, which gives to the epi- glottis, when seen in its entirety, its foliate appearance. But the free edge of the valve is more often turned upon itself, so that in the reflexion the notch is lost sight of, and the border appears round. In some cases, on account of the inclination of the epiglottis, only the profile of its free edge is visible in the mirror. In these cases the valve is repre- sented by a thin line. As a ride, there is seen (Figs. 24 and 25)— 1st, A portion of its upper surface on either side {u) ; 2ndly, its free edge and a smaU portion of its under surface turned up in the centre, and forming a kind of Hp {I) ; and 3rdly, another portion of its under surface, below and behind the lip, projecting as a rounded prominence —the cushion (c). The upper surface is of a dull pinkish hue ; the lip is of a decided yellow colour, though it has a slight shade of pink ; and the cushion is invariably bright red. In some cases the whole of the under surface of the epiglottis is seen, and then it is of a bright red colour. This normal coloration of the under smface of the epiglottis is apt to be mistaken (by those unaccustomed to the use of the laryngoscope) for congestion of the mucous membrane. Above the epiglottis, the glosso- epiglottic folds {g e) may be seen, passing upwards and backwards to the tongue, the posterior superior border of which appears as a horizontal uneven line. 240 DISEASES OP THE THROAT AND NOSE. The cmj-epiqlottic folds (ae) which form the lateral houndaries of the upper laryngeal apertiu;e, can be seen m the mirror extending obliquely downwards and backwards from the epiglottis to the arytenoid cartdages. Near the latter are the slight pinkish prominences of the cariilage^ of Wrisherg (cW), and a little beyond the cartilages of Wris- berg, in the same fold of mucous membrane are two other smdl prominences, the capitula Santorim {cS), surmounting the aiytenoid cartilages. Fig. 24.— Labyngoscopic Dea-wing, 'dBA-WN widely APABT, AlfD THE Above akd Below the Glottis. i/e. Glosso-epiglottic folds. M 'Upper surface of epiglottis. I. lap of epiglottis. c. Cushion of epiglottis. p. Ventricle of larynx. a e. Ary-epiglottio fold. clF. Cartilage of 'Wnsberg. SHOmNG THE VoCAL COEDB Position of the vaeious Pabts DUEma Quiet Tnspieation. e S Capitnlum Santorini. com. Arytenoid commisBure. V c. Vocal cord. V b. Ventricular band. p V. Processus vocalis. c r. Cricoid cartilage. t. Rings of trachea. com ■n^.-m-TKia WOWING THE ApPEOXIMATION IN THE Act of Vocalization. j5 Fossa innominata. sp. Sinus pyriformis^ ck. Cornu of hyoid bone. cW. Cartilage of Wnsberg. cS. Capitulum Santorini. a. Arytenoid cartilages. com. Arytenoid commissure. pv. Processus vocalis. THE LAEYNGEAL IMAGE. 241 The cartilages of Wrisherg generally appear round, but sometimes, especially in thin people, they have a triangular shape-the apex of the triangle being directed outwards. The capitula Santorini have a roundish shape in the healthy larynx, and like the cartilages of Wrisberg are most distinct when the vocal cords are approximated. But the clearness mth which these small laryngeal cartilages can be seen, de- pends also upon their degree of development, and upon the amount of submucous areolar tissue surrounding them ; some- times the cartilage of Wrisberg is not to be seen at all, whilst occasionaUy there is a smaU cartilage between it and the capitulum Santorini. The breadth of the ary- epiglottic folds varies in different people and in different states of the larynx, being greater when they are relaxed, that is, iu inspiration, and narrow when they are tense, as in the approximation of the cords— especially in the production of high notes. The ary-epiglottic folds have been well described by°Stoerk, as having almost the same colour as the gums. _ The cartilages of Wrisberg and Santorini are of a rather brighter and deeper colour than the rest of the mucous membrane. The arytenoid caHilages (a) are easily recognized by the small cartilages of Santorini which surmount them. _ They can be best seen when the vocal cords are approximated. The mucous membrane covering them is generally of a rather redder tinge than that forming the ary-epiglottic folds. Between the arytenoid cartilages is a fold of mucous mem- brane, the inter-arytenoid fold or commissure, which is most apparent when the glottis is widely open (Fig. 24, com); when the arytenoid cartilages are approximated, the com- missure folds together, and is directed backwards (Fig. 25, coin). It is of a yellowish-pink colour. The ventricular bands [vh), formerly called the false vocal cords, are the folds of mucous membrane which are seen below the ary-epiglottic folds, passing obliquely in the antero-posterior diameter of the larynx, from the arytenoid cartilages to the epiglottis. They are thick, rather pro- minent, and of a deeper red colour than the ary-epiglottic folds. Being rather thinner, and more prominent at their lower edge (which borders on the ventricle) than elsewhere, this part has a lighter tint when illuminated than the rest of the ligament. When the vocal cords are approximated a small depression — the fossa innominata {fi) — may be seen near the epiglottis between the ventricular bands below and the ary-epiglottic folds above. E 242 DISEASES OF THE THROAT AND NOSE. The openings of the ventricles (v) can sometimes be dis- tinguished as dark lines, between the ventricular bands and vocal cords. They are best seen in the healthy larynx of a thin subject— especially when there is a slight disposition to spasm. The vocal cords {vc) when visible, cannot be mistaken. They appear as two pearly-white cords, passing from the base of the arytenoid cartilages to the angle of the thyroid cartilage. On inspiration, they appear almost to touch each other at their anterior insertion, but to be separated from a quarter to half an inch posteriorly. On phonation, they become parallel, and appear to approximate. Each vocal cord is seen to terminate behind in the angle at the base of the arytenoid cartUage, caUed the vocal process (vjy). On inspiration, this angle Is directed outwards, and the glottis has a lozenge shape ; but when the vocal cords approach one another, the angle is tui-ned inwards. This process divides the inter- cartilaginous and inter-ligamentous portions of the glottis. _ Below the vocal cords, appears the broad yellow cricoid cartilage (cr), and below it, again, the rings of the trachea (t) ■ are seen elevating the mucous membrane, which between them is of a pale pink coloiu-. Occasionally, two indistinct dark circles (the openings of the bronchi), on either side of a brif^ht projecting line (the angle of division between the bronchi), indicate the bifurcation of the trachea, and in some rare cases a ray of light may even be thrown down the right bronchus. . . ^ .-4.1, Thouf^h external to the larynx, it is necessary to mention tbe MS pyriformis (sjj) m which foreign bodies are extremely likely to become lodged. It is bounded on the inner side by the ary-epiglottic folds, and on the outer side by the inner surface of the thyroid cartUage. LARYNGEAL INSTKUMENTS. In operating within the larynx the laryngeal mii-ror should be held in the left hand, and the instrument m the right. It is seldom necessary to employ an assistant to steady the head except in the case of very young children, before Sribrg the various instruments in detail, I may observe that whilst most Continental practitioners, as a ™le, use laryngeal instruments curved like a catheter, f^^^ .^l^^J^f ^ employed those of a more angidar form, and this tjpe is LARYNGEAL INSTRUMENTS. 243 universally used in England, and pretty generally in America. Li a catheter the two extremities are at right angles to each other; but the angle is reduced to a minimum by a large curve or sweep. This curve, though well adapted for the urethra, is much less suitable for the larynx ; and if, on the other hand, the right angle, slightly smoothed do^vn, is left, the instrument in passing into the larynx is kept free of the epiglottis. My meaning will be at once clear on reference to Fig. 44. It will be seen that both the catheter-curved instrument (indicated by dotted lines), and my rectangular instrument reach the same spot ; but whilst the former touches, and even presses against the epiglottis, the latter avoids it. Hence the superiority of the rectangular instriunent. Probes. — It occasionally happens that it is desirable to intro- duce sounds withm the larynx. By means of such instru- ments the origin and density of a growth may sometimes be ascertained, when with the unaided laryngeal mirror the Fig. 26. — Laetngeai, Peobes. information cannot be obtained. In cases of ulceration over the arytenoid cartilages they often enable the practitioner to ascertain the extent of the burrowing and the condition of the cartUages themselves. In cases of altered sensibility of the larynx, relative differences may be ascertained. Brushes. — For applying solutions to the larynx, squirrel's or camel's-hau- pencils, either cut square at the end or pointed, according as a large surface or small spot has to be touched, and firmly attached to aluminium -wire bent at an angle of about 90° wiU be found most suitable. Brushes of different lengths and sizes are required, according to the situation and nature of the case. For ordinary use, three brushes will be sufficient, and these are made of definite dimensions. The shortest size (jSTo. 1) measures two inches in length from the angle to the end of the brush. The length in the mecUum size (Ko. 2) from the angle is two inches and a half. In the longest (No. 3) the length is three inches. In 244 DISEASES OP THE THEOAT AND NOSE. all cases the metal slianlc of the instrument between the handle; and the angle should measure at least an inch, and the Avooden handle about seven inches. The handle should be octagonal and should taper down toAvards the metal; and m hospital Fig. 27.— LAETNGEAii Bbtishes. practice, or where a large number of cases are seen, it saves a ^ood deal of trouble in sorting and selectmg to have the handles of brushes Nos. 1, 2, and 3 coloured, white, red, and black respectively. The Croup-Brush (Fig. 28) is made ol j'j.fj^ 28.— The Ceoup-Beush. ,n^>vpl'", tail and the hahs covering the sides of the brush Z dtltt^^^^^^^^^ It is -ainly useful for detachmg 'SLe membraie from the larynx and trachea m croup, biit t maH?^ employed for applying remedies in the case of chMma-when the laryngoscope cannot be used. Sponges were at one time much used by Dr. Famel, LARYNGEAL INSTBUMBNTS. 245 of Paris, for applying sohitions to the larynx, and tliey possess tlie advantage that a perfectly new sponge can be used for each patient at every visit. I have lately employed a very excellent American sponge-holder in this way, after havuig slightly modified the instrument in order to make it quite safe. To prevent the possibdity of the sponge dropping, I have added a Fig. 29. — The Sponge-Holdee. A, the holder open, b, the holder with sponges. (The safety-wedge (a) is raised in A, but closed in b.) wedge, which fixes the blades of the sponge-holder immovably together. Dr. P. C. Smyly, of Dublin, uses cotton wool attached to a piece of bent aluminium wire by means of strong thread ; the instrument is thrown aside after being once used, and fitted with a fresh piece of wool for each occasion. Laryngeal Injectors. — Various kinds of syringes have been invented for injecting fluids into the laryngeal ca\dty. I do not recommend this method of treatment, but those who wish to practise it will find Hartewelt's Drop Injector (Fig. 30) a very manageable instrument. It is a hollow tube made of vulcanite, and suitably curved for introduction into the larynx. At the junction of the shanlc and the handle, on the upper part of the mstrument, is a small cavity covered with a drum-like piece of caoutchouc and communicating with the interior of the tube. The injector is filled by pressing the air out of the cavity, and inserting the point of the instrument into the solution to be used. This instrument is made in two parts, so that the same handle can be employed -with different tubes, and the points of the tubes are also made in different ways, some having a number of small holes, so that the stream is diff'used : while 246 DISEASES OP THE THROAT AND NOSE. some have only a hole at one side, so that the fluid passes only in one du-ection, &c. &c. The injector is held between the thumb and seeond finger, and the index finger remams free to press on the elastic drum when the point of the instrument has been passed into the larynx. The late Dr. Gibb used a small syringe with a fine curved silver extremity, terminatmg Fig. 30.— Haetewelt's Drop Injectoe. in a smaU, finely perforated baU, by which showers of " the solution were distributed through the larynx." The principal obiection to the use of injectors is that they have a tendency to cause more spasm than brushes, and with them it is more difficult to limit the amount of the apphcation, or to confine it to certain spots. Pig. 31.— Peofessoe Siegle's Iuhaiee. Tvlialers—YoT the application of liquids to the larynx in the form of a very fine spray many kinds of "atomizers" LARYNGEAL INSTRUMENTS. 247 have been invented ; but Bergson's tubes have, in point of fact, superseded all others. These are applied in Dr. Andrew Clark's handball Spray-Producer, in which an india-rubber ball supplies air as the motive power, and in Professor Siegle's apparatus (Fig. 31), in which the atomization of the fluid is effected by ste°am ; both are good mstruments. The ordinary handball Spray-Producer is so well known that it does not require to be illustrated. Dr. Solis Cohen's Spray- Producer, in which only a single ball is used, is an extremely useful Tig. 32. — De. Solis Cohen's Single-Ball Atomizer. a glass points at right angles ; 5 vulcanite tube for preventing dispersion of spray ; c bottle containing medicated fluid ; d india-rubber air ball. instrimient. There is no advantage in having a continuous spray for the throat, as the spray cannot be continuously inhaled. Indeed, it is more convenient to have the spray interrupted, as it can then be easUy drawn in at each inspiration, and does not continue to flow during expu-a- tion and periods of rest. These instruments certainly produce a finer spray than those in which the fluid is pulverized by being projected in a fine jet against a disc or button ; but they are open to the serious objection, that in all cases a very strong current of air or steam accompanies the atomized liquid. Where any dyspnoea exists, this is a very objection- able feature. The employment of atomizers in throat affec- tions is more particularly indicated in cases where, from circumstances, the patient cannot visit his medical attendant sufficiently often, and is thus obliged to carry out the treat- ment himself. I do not recommend the use of these atomizer's .for the inhalation of caustic solutions. 248 DISEASES OF THE THEOAT AND NOSE. For the inhalation of volatile medicaments, a supply of steam is aU that is required, hut the process can be best carried out Avith the aid of one of the numerous inhalers now ui vogue Those instruments are most effectual in which the patient inhales steam together with air, which is drawn tln-ough the hot liquid, and thus becomes thoroughly impregnated with the active principle of the medicament. In inhaling steam iuAvMch there is no such aerial cm^nt the remedy acts much more feebly. The Eclectic Inhaler (Fig. 33) is A B Pig. 33. — The Eclectic Inhaiee. and with the sides ol tne vase iiiawu ,°, ^ the tumbler dip down into it, tumhler forms the covenng of the v^^^ leaving an air chamber between the P'^i^^l^^^^^^ jid dip down only about quantiV of water^ the Bide| of^be ^v^rted tamblBr or lid mp.^ ^^rtoratk ;rith half-an-mch below the ^ater-lme. ^i*^^^ f ^ould be the i-im of the smaU ho es, ^^en m ^, and^^^^^ ™TX The apertui-eH both above and below tumbler 18 perforated m the samewayat^^^^ i ^^.^^^ .^^^^^^^ air rushes communicate with the ^'F„^f'^™°%vgn throu-h the au- chamber, again throush through the vanoiis holes above at J taenmroua^^^^^ the se'ries of boles at f J^'f tL W ^«"ace?f the Ud is a projecting courseof the arrows. In the centre 01 uieup^ extremity with a nozzlQ.to whichia -attached a flexible t^^e- Pr°v^ett .^^^^^ lid, through double-valve earthenware mouth-piece iuct^^^^ l ^^^^ ^^^^^ ^ ^ g_ Tt^^h^n^SThf^ae'eTs^ra^^^^^^ - - ^ perhaps the most perfect of these instruments, but it is rather cumbersome. LARYNGEAL INSTRUMENTS. 249 Martindale's Portcable Inhaler is an excellent apparatus, and fulfils most of the conditions of the Eclectic Inhaler, whilst it is much cheaper, and, being made of tin, is easily carried about without any risk of brealdng. Fig. 34. — Maetindaie's Poetable Inhaiee. A shows the inhaler ready for use, with a woollen covering, to prevent rapid coohnfr. B is the uncovered inhaler, c is its upper portion, which takes off for cleansing the apparatus, and to facilitate the packing. Fig. 35.— Bullock's Hospital Inhalee. A shows the inhaler ready for use. b is the lid with nose-piece for nasal inhalations. Bullock's Hospital Inhaler is cheap and serviceable. 250 DISEASES OP THE THROAT AND NOSE. It is made of stoneware, and has a tin lid and spout, tlie montlipiece of which is covered with india-rubber. Dr. Lee's Steam-draught Inhaler i is a very useful instru- ment, as it delivers the steam, and thus dispenses with the necessity for an inspiratory effort. For the inhalation of burning substances, such as nitre, stramonium, arsenic, &c., no apparatus is absolutely necessary, as they can aU be employed by merely being lighted on any non-inflammable substance. A special apparatus, however, such as the ruming-Inhaler, is useful, particularly in employ- ing nitre-papers. i j • i i.i • Steam Kettles are useful in laryngitis and diphtheria. The best apparatus of this kmd is the Ventilating Croup- Kettle, of Messrs. AUen (Fig. 37), which constantly delivers a small quantity of steam in a state of very fine subdivision. Fig. 36. — The PomNG-IiraAiEE. This apparatus consists of a cylindrical earthenware ve.sel-avas^in f^^^^ four inches high and tfro inches in diameter. An open wre diaphragm occupies the upper part of the cylinder. J«suy?Zafor6-. — Powdered substances may be introduced into the larynx either by insufflation or by various kinds of injectors. This plan of treatment is of very ancient origm, having been introduced by Areta^us. The insufflators m use are (1^ that of Kauchfuss (Fig. 38), in which tne POwder is expelled by pressure on an elastic ball at the end of the instrument ; and (2) the Tube-Insufflator (Fig 39). In h instrument a piece of elastic tubing is attached to the proximal extremity of the vulcanite tube. With the free end of the 1 Mauufactured by Messrs. S. Maw, Son, and Thompson. LARYNGEAL INSTRUMENTS. 251 tubing ill his mouth, the operator blows the powder into the patient's larjaix. This instrument is preferable to that of Eauchfuss, as the sudden pressure of the thumb on the ball of the latter instrument alters the direction of the Fig. 37. — Messes. Allen's Ventilating Ceotip- Kettle. Tig. 38. — De. Ratjckfuss' Injectoe. a a moveable tubular coveriEg. i the cavity into -wbioh the powder is put. EiG. 39. — The Tube-Insuetlatoe. a a moveable tubular covering, i the cavity into which the powder is put c . top, wbich closes the passage until it is pressed down, d valve which aUows me air to pass towards the laryngeal extremitv of the iustrument, but prevents the patient expiring or coughing through the tube. point of the injector, and thus renders the accurate application of the remedy very difficult. Porte-Caustiques.—F ot: applying solid nitrate of silver to :252 DISEASES OF THE THEOAT AND NOSE. the larynx, tlie only instrument which is thoroughly safe, and at" the same time easy to use, is the Laryngeal Oau- terizer, first recommended hy Lewin. It consists ot a piece of aluminium wire, hent at the same angle, and of the same length above and helow the angle as the laryngeal brush. The wire is roughened at its extremity and then dipped into some nitrate of silver fused over the sphit lamp. In this way a certain quantity of the nitrate adheres firmly to the wire. An ingenious porte-ccmsiujiie has been invented by Dr. Fauvel, in wliich, wliilst the stick ot nitrate of sdver is safely enclosed, the point, by a spiral ■spring behind it, is always kept protruding. Protessor Stoerk, of Vienna, also, when laryngoscopy was quite m its infancy, contrived a porte^caustique in which the caustic remains concealed till brought to the part desu-ed to be touched, when, by pressure on a spring m the hancUe, it is made to protrude. My laryngeal lancet is provided with a :smaU piece of aluminium we, which can be fitted on m place of the cutting blade ; in this way it becomes a guarded porte-caustique. The nitrate of silver is attached to the wue by fusion in the way akeady described. Besides these instruments, various others have been in- vented, but the simple aluminium we answers the pm-pose ^'^L ar X^ea^^^ec^j-orZes.— Thes^ mstruments are used daHy by Fig. 40.-THE Authoe's Laeyngeai- Electeodes and Necklet. , , , „ a n,ptalrm''bv •which the electrode is connected A, the>ryBgeai e ecteode a, l^l^^^^-^Zx^.^ri. machine ; 6, the ptre^i^r by a chain either \nth a battel y oi iw^ b handle, d. of awe commumcating mtha^^ c^^^^^^^ ^. ^^ ^ (^^^i is is pressed upon, touches 6. J-'?f ^^f^ -^^u / This completes electi-ode No. l. insulated in caoutchouc), '^^f^ current to the posterior .g represents the ^Pad^-shaped deotiode for aPP^i^|^^ ,s •connected with the apparatus producing the electricity. LARYNGEAL INSTRUMENTS. 253- nearly all laryiigoscopists. They are so constructed that the- current does' not pass till the metal point or sponge is in contact with the vocal cords. The instrument is held in the hand between the thumlj and second finger, and when the sponge has been placed in the desired position, the operator yvith his index finger presses on the key in the handle, and the electric current passes through the larynx to the skin externally. At the same time the patient Avears a necklet communicating with the other wire of the battery. In Dr. Eauvel's modification of my instrument (Fig. 41, a),. the two poles are united in the same handle. _ The two rods are carefully isolated, and only when the little key on the upper part of the instrument is touched does the current pass between the two brass knobs. In a third instrument here shown (Fig. 41, b), the electrodes are more widely sepa- rated, so that they can straddle across the ary-epiglottic fold, and embrace the lateral-crico-arytenoid muscle. Tliis arrange- ment is useful for limiting the electric current to the thyro- arytenoideus muscle. Fig. 41.— Laetngeai, Electeodes Nos. 2 aut> 3. A represents Dr. Fauvel's modifleation of my instrument, -wliicli is called No. 2 eleetrode. The current passes between the two knobs at c. b represents the adduc- tor, or No. 3 electrode. It is inti-oduced into the lai-ynx in such a way that the pole, 0, is in contact with the vocal cord, and u passes mto the hyoid fossa. In this way the lateral crico-arytenoid is embraced between the two poles. The extremity of the hyoid electrode should be about five-eighths of an inch distant from, and slightly posterior to, the pole which is applied to the vocal cord. Laryngeal lancets are of various kinds. My own instru- ment consists of a small double-edged knife or lancet, which is contained in a hollow tube, suitably curved for introduction into the larynx. The point of the lancet is concealed in the duck-billed extremity of the tube till forced out by pressui'e on a spring in the handle. The stock of the instrument is provided with tubes bent at different angles, and below the angle is a joint wliich enables the operator to lengthen or shorten the tube. This arrange- 254 DISEASES OF THE THROAT AND NOSE. ment allows for the varying inclination which the plane of the laryngeal apertme bears to the horizon, and renders the lancet fit for operating either at the upper or lower part ot Fig. 42.— The Guaeded Laryngeal Lakcet and vaeious Kniyes. 5p. thespring ^^^^^^.eesj^^e lancet ; when " ^P^-d^^^^^^^^^^ barrel and stock of tl^e mstoument At t^^ ^Tskorter or^ger tube can be Tobold. Fig. 43.-THB Aothob's Cutting-Foeoeps. A, the lateral forceps. B the antero-posterior forceps, forceps. D, punch-forceps. c, spoon-shaped fi . in.v.v The lencrth of the blade is regulated by a screw the larynx, ihe en^tn ^^^^^^^^^ ^^^^^^^ xn he 1^^^ J^^X';^^^^^ extremity is brought opposite and second hngei, ana wnou luo _ i,p i-n-p^ses on the part which the operator wishes to lance, he presses LARYNGEAL INSTRUMENTS. 255 the spring in the handle with liis index finger. Dr. Tohold's. nn"uarded knives give more power to the opemtor than can be°obtained with the 'moveable concealed blades of my pro- tected Laryngeal Lancet, but their iise should be confined to Fig. 44. — The Authoe's Common Lateral Foeceps, SHoira in situ. the hands of those thoroughly skilled in the use of laryngo- scopic rnstrimients. The common laryngeal forceps are made of difierent 256 DISEASES OP THE THROAT AND NOSE. lengths and curved at different angles. Some open like ordinary forceps, laterally (Fig. 4.3, a), Avliilst others open hack- wards and forwards (Fig. 43, b). The instrument is shown in situ in Fig. 44. I now scarcely ever use any other instru- ment than these forceps for removing laryngeal growths. Larger experience has also convinced me that forceps should not he Fig. 45. — De. Fa-ctvel's Foeceps. 1, 11 +1,0 i-TisfTiiment. sliowing the ai-rangement for locking the ^rette°xL MadTf Tthe Wades, showing the iBanner blade!'" B,"tlie lateral blades ia which one blade plays in a slot. slender, hut, on the other hand, rather stout. There is too much vihration and too little &mness in the slender instru- ments, and though they look much more suitahle for delicate operations, carried out with the laryngeal mu-ror, they are m LARYNGEAL INSTRUMENTS. 257 point of fact less serviceaLlo. Dr. Fauvel, who lias been so remarkably successful in the removal of growths from the larynx, uses even stronger and larger forceps than myseit. In order to grasp the gi-owth more firmly he also has a catch fixed to the rings of the handles, so that, when desired, the blades can be made to lock. » v ^. p The tube forceiis consist of a steel tube of a diameter ot one-tenth of an inch, containing the forceps. It is bent at an FiQ. 46. — The Authob's Tube-Foeceps and Scissobs. Sp, the spring', by pressing on which the tube is forced over the base of the forceps. 6, the joint at which longer or shorter tubes may be applied, and the blades taken out and cleaned. (This joint has been made unnecessarily large by the draughtsman. ) r, the ring, by turning which the forceps revolve so tha.t the blades open in any direction. ;S'c, the screw for taking the instrument to pieces, cleaning it, &c. 1, the perpendicular blades. 2 and 4, horizontal blades. 3, the scissors, with hooks attached to them. angle of 90°, but to the same stock barrels of different angles can be applied. Just below the angle is a jomt wliich enables the practitioner to clean the forceps and apply shorter or longer blades, as the case may require. The spring which forces the tube over the forceps is at the anterior and upper part of the handle ; and the operator, holding the instrument between his thumb and second finger, presses on the spring with his index finger. At the posterior part of the handle is a ring, by wliich the forceps can be made to revolve, and in this way the blades can be made to open backwards and forwards, or from side to side. This arrangement enables the operator to seize excrescences, whether they grow from near the anterior msertion of the vocal cords, from the ary- tenoid cartilages, or from either side of the larynx. The blades of the forceps have sharp-cutting teeth aU round their edges. Tor most cases, the blades wliich pass down perpendicularly from within the tube containmg them are convenient ; but S 258 DISEASES OF THE THROAT AXD NOSE. angle sometimes where the growths are thin and membranous, and have an extensive origin from the side of the larynx, for- ceps, with blades open- ing horizontally, will be found more suitable. In this case the forceps have in fact only one moveable blade, which is at ri'ght angles to the shank,' the other blade being let into the tube : the two blades of the forceps close when the tube containing the upper blade is forced down by the pressure of the index finger on the spring m the handle. At the joint below the of the instrument scissors can be fitted in- stead of the forceps. In order that the blades should readily cut, the shanks of the scissors should cross one another above the blades ; the scissors have hooks on each blade, which seize the divided particles and prevent their falling into the trachea. Schroetter's laryngeal forceps are of the tube character, but the handle is placed at an oblique angle to the shank, so that the operator's hand is kept to one side, alto- gether out of the field of vision. The upper blade is fixed, being m fact part tbP tube whUst the lower blade is attached at right angles tt ^soM wire which moves within the tube. In order to rLcl grottL in different parts of the larynx, several tubes Fig. 47. -Professoe Scheoetxee's FOECEPS. LARYNGEAL INSTRUMENTS. 259 are required for the same handle, as the forceps liave only •one movement (viz., the upward movement of the lower Fig. 48. — Professoe Stoeek's GuiLLOTnra; xsd Forceps. A, wire fcraseur. b, puiUotine. c, ditto (larger), d, e, and p, forceps. candH, improved gmllotine, avoiding the Iosb of space in b and c. h shows the guiUotine open. G, the same instrument half closed. 260 DISEASES OF THE THROAT AND NOSE. Hade), which is brought about by touching a slide m the handle of the instrument with the thumb, ihese iorceps are only adapted for removing yery smaU growths but they are particularly convenient for effecting evulsion at the anterior commissure of the vocal cords. i r tcraseurs of different construction have been used for the removal of laryngeal growths with more or less success since the invention of the laryngoscope.^ this country Drs. ave employed them ; d with a kmd of dart, ., has been recommended , entertained the objection, be ctfeplaced, and that the- Walker, Gibb, and Georg^^ whilst in France an ecraseri which is said to transfix the by Moura-Borouillou. , To these instruments I alws that the wire was very likely ....j^....— , crowth could only be accidentaUy ensnared after repeated trials This inconvenience was, however, overcome by iro- fessor Stoerk, who had an ^craseur constructed m such a way that the wire is concealed in a solid loop of metal. This- prevents the wire being pushed aside when the operator oleeds to put it over the growth. The mstrument i^ tendered mAch more serviceable, but i really acts mo- on the nrinciple of a guiUotim than an ecraseitr, and, indeed, ptfL 01 Stoerk employs the same handle with a cixcidar knife instead of the wire. For operating on jry laje o-rowths I have, however, used a modification of ^toerk s instruments in wlrich, by means of a cog-whee , that can be red bi he index finger, the wire slowly crushes tWgh the growth Fia. 49.-THE AiTTHOE's Guaeded -Wheel Eceaseuk. . . ,4- o-narded-wheel ecraseur. Two S^i""! bt ^^'oyed were brought by mo before L Pathological Society ^ some years ago. 1 « Trans. Path. Soc," PP- 52 and 53 (1870). DILATORS OF THE LARYNX. 261 DILATOES OF THE LAEYNX. For dilating the larynx vihen it has become blocked up by organized membrane or by cicatricial tissue, various dilators have been invented. In most cases the use of these in- struments is facilitated by the previous performance of tracheotomy, which is almost certain to have become necessary. EiG. 50. — The Authoe's Dilatok. A, the instrument closed ; by turning the screw, s, the blades separate, whilst the dial, d, shows the extent to which the dilatation has taken place. The screw dilator is an instrument which I have occa- sionally used for the last fourteen years. It consists of three blades which, when united together, form a solid instrument easily introduced into the larynx. When the instrument has been passed imo the constricted larynx, a screw at its proximal extremity enables the operator to open tlie blades 262 DISEASES OF THE THROAT AND NOSE. and thus effect distension, tlie degree of which is shown on a dial placed near the screw. ' Professor Navratil, of Pesth, has invented an instrument very much on the principle of my dilator, hut much more perfect in its detaUs, and consisting of four segments instead of three ; moreover the dilatmg action in his instrument is confined to its laryngeal portion, whilst in mine it extends a little ahove its angle. The only ohjection to Professor NaAa-atil's instrument is its extremely complicated construc- tion, which renders it liable to get out of order and difficult to clean. Fig. 51.— Peofessoe Naveatil's Dilatob. the instrument into tje mouth, ine ouve sna^^^^ 4,1 to C centimetres, and its diameter is from 12 and -rf) con- and from 5 millimetres t° J.™i^^*\^^hS'ttoee ?he ^segments 4n be sista of four «egl>ients, each segment ^ milliiletres by turn- made to extend symmetricaUy to a fj^^^^Pf between the handle and its SrthTa^a^Ua^ta^tion that has taken place. Dilating were first introduced by Pmfessor Schroetter, nnd the profession is greatly indebted to that physician for d JeW^^^^^^ of a very difficult class of ca.es.. Mes or Schroetter originaUy employed hollow curved tubes, of vulcanite of various sizes. Small tubes are first used, and sysequently when the larynx is more dilated, larger tii^l^es can breiSloyed The fact that these tubes (although hoUow and DILATORS OF THE LARYNX. 263 thus permitting the patient to breathe) cannot be tolerated for more tlian a few seconds on account of the pharyngeal irritation and retching which they produce, led Professor Schroetter to invent the instrument now to be described. Tlie Laryvgcal Dikdhuj-Plug. — This instrument consists of a leaden plug, which is temporarily attached to a suitably curved hollow tube by means of twine passing through the, tube. It can only be used when tracheotomy has been previously performed, and a canula is worn with an opening in its upper surface. The plug is introduced into the larynx, and its lower end, which is perforated by an oblique passage, passes into the tracheal canula. It is retained in this position by a bolt, which takes the place of tJie ordinary inner tube of the canula. "When the plug is thus fixed in position the laryngeal tube is withdrawn, whdst the twine which is left pi'o trading from the mouth can be tied round the neck or behind one ear. When it is desired to with- draw the instrument the bolt is remoAa^d from the canula and Fio. 62. — Peofessoe Scheoettee's Dilatoe. A. The instruinent ready for use. It is a hollow, curved tube, fitting into aper- f orated handle, and terminating in a metal plug (x) . The latter is kept attached to the tube by a piece of twine, which passes through the tubular instrument, and is fixed to the proximal extremity of the handle by a clip. The metal plug has a ring at its upptr part and a smaU canal [y) passing obliquely through its lower extremity, b is a fine silver rod, by means of.which the twine is drawn through the tube when it is being prepai'ed for use. c corresponds to the inner tube of a tracheotomy canula, which, instead of being continued as a tube, termi- nates in a bai' (2), passes through the plug when in situ (i.e., in the contracted larynx) and bolts it in position. 264 DISEASES OF THE THROAT AND NOSE. the. pin- is drawn up from the larynx by means of the twine. It nL be allowed to remain in the larynx for an honr or half an hour the first time, but this period may be gradually increased until the patient retains it for the whole day. The Catting-Dilator.-Dv. Wliistler^ has invented a very in "enious cutting-dilator, which is particularly serviceable for dividing webs or membranous formations. Fig. 53.— De. Whistlee*s CuTiiNG-DiLiTOE. c, the blade altogether removed from its covermg. This instrument consists of a pointed, oHve-shaped body, placed at the end of a suitably-curved shank, and con- Cng within its interior a sharp blade which can be mad to protrude by touching a little key in the upper P-'t of th« handle When the instrument is passed into the laiynx anrexistinc. web is put upon the stretch, and thus rendered Se for division. The knife is so arranged that it can be nSe tS cut forwards towards the anterior commissure or Tckwards towards the inter-arytenoid fold, according to the situation of the stricture. ACUTE CATARRHAL MRVNGITIS. 265 ACUTE CATAERHAL LAEYi^GITIS. (Synonyms : Spurious Croup. Acute Catarrh of the Larynx. Acute Laryngitis.) Latin Eq. — Laryngitis acuta catarrhalis. French Eq. — Laryngite catarrhale. 'German Eq. — Akuter kehUtopfkatarrli. Italian j^;*?.— Catarro acute della lariuge. {See also (Edematous Laryngitis.) Definition.— ylcii^e catarrhal inflammation of the mucous membrane of the larynx, seldom dangerous to life, giving rise to hoarseness or aphonia, and sometimes to slight dyspnoia and stridulotis breathing in children, in ivhom, horvever, it almost invariably ends in resolution. In adidts, it often passes into the chronic form of inflammation, and in very rare cases may result in oedema. History. — This disease was partially described by Millai',i more than 100 years ago, but that observer gave an obscure picture of the affection from mixing up catarrhal laryngitis with spasm of the glottis. Hence he was led to regard the complaint as a neurosis, and to recommend anti-spasmodic remedies. Guersant^ first gave a clear account of the patho- logy of the disease, and employed the terms "faux croup " and " laryngite stridideuse." Etiology. — The causes which provoke acute catarrhal in- flammation of the larynx are such as favour analogous affections of mucous membranes generally, amongst which, in so-called temperate climates, " catching cold " is the most common. Cold draughts of ah', whether inspired directly, or bearing on the neck and ears externally, are particularly liable to give rise to laryngeal catarrh. Exposure of the body in general to cold, and especially allowing the feet to remain wet and cold for any length of time, are also common causes of an attack. As Krieger^ well points out, children whose vital power has been lowered by prolonged confinement to, the house in bad weather often catch cold in their fii'st walk through dusty streets on a ^vindy day. But frequently the cause of laryngeal catarrh is of a more local nature. Thus 1 " Observations on Asthma and Hooping Cough." London, 1769. 2 " Revue Medicale," Octobre, 1829. 3 " Aetiologische Studien." Strassbiu-g, 1877: Cited hj Bauch' fuss: Loc. oit. 266 DISEASES OF THE THROAT AND NOSE. violent functional efforts (as in giving tlie word of command, preaching, singing, &c.), as weU as straining the parts ni cough- hv are not uncommon causes of it. Hot alcoholic drinks,, excessive tobacco smoking, dusty air, irritating vapours,, foreign bodies accidentally entering the larynx, may also be enumerated as frequent excitants of the disease. Or it may be propagated from the nares and pharynx, the more severe forms of inflammation of the latter region bemg especially prone to spread to the neighboiu-mg region of the larynx Extension of the disease occasionally takes place from below, the bronchial tubes being first affected ; but the opposite sequence is more usual, the laryngeal inflammation passin'T off with the occiu-rence of bronchitis. Eelaxmg habits^and indoor occupations undoubtedly predispose to the disease At the Hospital for Diseases of the Throat, catarrh of the larynx is much more often met with among tailors, shoemakers, house-porters, and people thus engaged than amon'^ coachmen, cab-drivers, policemen, and others who are constantly exposed to the most inclement weather. Previous attacks, especially if several times repeated increase the susceptibility of the indiAddual to a renewal of the affection. Males are more Hable to it than females, and adults_ than cliildren, but in yoimg subjects the cUsease gives rise to much more marked symptoms, and hence attracts more attention. Laryngeal catarrh is also a very usual accompani- ment of hay asthma, and is often met with m the exan- themata, especially in measles. Symptoms.— The patient complains at flrst of slight dryness or soreness of the throat, with hoarseness, and a disposition to coucrh. This sensation varies from a mere feeling of tickbng or roughness, to a sense of constriction about the throat with slight odynphagia. It rarely happens that mampulation of the or-an from without causes pam, but gi-eat uneasm^ss i* sometimes experienced on attempted phonation. The voice- Hsually at first hoarse or defective m timbi-e, but afer^ warS it^may be extinguished. The cough may be alto- gether absent, but it is generally rather shrill, cases may be aphonic. The respu-ation is not aff^^teel a rule,\ut, as'wiU be presently shown, ^l ^^^o^^s embarrassed in chHdren, the narrow area of the glottis in young subjects. easUy resulting m some steno s and a corresponding diffieulty of breathmg. In the adult, on the other hand, considerable swelhng may ensue, without cur tauSg the breathmg space. The inspiration is, however, ACUTE CATARRHAL LARYNGITIS. 267 generally a little prolonged and occasionally associated with stridor, and mucous rales can usually be heard on auscultat- ing the larynx. Slight mucous expectoration accompanies these symptoms, but if the secretion becomes thick, purulent, and abundant, it may be regarded as coming from the bron- chial tubes. In chikhen there is sometimes marked fever, the tongue is white and fm-red, with red tip and edges, the pulse frequent and hard, the skin hot, and the face flushed. In these young subjects suffocative attacks, occurring during sleep, are an important featui'e of the disease. This symptom has given rise to considerable confusion, both in theory and practice, as well as to much warm debate in medical circles. It generally occurs in children Avho, with- out constitutional disturbance, have manifested dimng the daytime some degree of hoarseness and cough, but to such a slight extent as not to excite any apprehension. At night the scene is suddenly changed. The child who has been sleepuag some hom's wakes up in ten-or, its breathing is laboured, insphation prolonged and noisy, voice and cough husky, features congested, and its whole aspect one of impending suffocation. In the general alarm the little patient is apt to be drugged and nauseated, proceedings which a knowledge of the actual state of things will show to be for the most part unwan-anted. Tliis form of the disease has been called laryngitis stridulosa, and it has been gene- rally thought to be due to spasmodic action of the adductors of the vocal cords. It is probable that muscular action operates as a secondary cause, but that it depends primarily on the laryngeal secretion becoming insjiissated during sleep, when the mouth is often open. Collecting in this state in the very narrow glottis of the child,* and adhering to the vocal cords, the thickened mucus gives rise to a gradually- increasing impediment to respiration, till the terrified little- patient awakes in a storm of anguish. Between crying,, coughing, and vomiting the difficulty is got over, and the- child shortly falls asleep, to repeat, it may be in a few hours, a scene which to the uninitiated presents aU the features of impending death. The larynr/oscopic a2-)pearances vary with the degree of severity of the attack, as well as with the stage at which the inspection is made. In mild cases, and at an early period, the whole of the mucous membrane is of a bri'i-h't red colour, though the hyportemia maybe gonfiued to certam '268 DISEASES OP TUE THROAT AND NOSE, parts, suclias the posterior extremities of the vocal cords the inter-arytenoid fold, or the ventricular bands feometimes there is distinct injection of the vessels, but usually the . congestion is general. Occasionally haemorrhage takes place either into the tissues or from the mucous surface. The latter variety has been called laryngitis hcemorrhagtca, .but it is . scarcely necessary to give a special name to so rare and acci- W'a condition. I have met ^xth a ew cases^ a^^^^ examples have been recorded by Navratil^ and Frankel. L these, as weU as in nearly all the other recorded cases, the congestion was sligM, and the haemorrhage abnost always Sed from some violent expiratory effort, such as cough- incr or vomiting. In more severe forms the mucous membrane is swoUen, as weU as red ; and when as frequently happens, the ventrictTlar bands are affected, the turgid state of these folds causes them to overlap the vocal cords so that the latter are entkely concealed, or seen only as slender threads of a redS Ihit. ^Vhen the ary-epiglottic folds are attacked they "eneraUy maintain their normal shape ; and, in these cases °the epiglottis is seldom inflamed to such an extent as 0 block out the view of the larynx. SmaU patches of shaUow ulceration, or erosions, which amount to little more than a . desquamakon of the epithelial layer of the mucous membrane and leave no cicatrices on healmg, are not unfrequently to be seen They constitute the Srosions glandulaires of French .aXrs", accorcLg to whom they ^^^r^:^^, the foUicles of the larynx. The point at wM^h the pus • escapes becomes a minute ulcer, which heals rapidly^ Var ous modifications of the mechanism of the lajTnx to which the objective phenomena already described are diie, may lo be observed. Thus the changes in vocalization, noticed at tt very crmmencement of the attack may be seen, in some case? to depend upon a protrusion of the swoUen m er-ary- • TeTddMdbetweeithevocal cords ; or ona similar obstacle at r So«- Boththese conations are however, quent when the PJ^^iJ^^ ' ^ f^^^ ^.argins presentuig a -LaryngoLBeitrage." Leipzig, p. 18. Cyclopedia of Med." vol. iv. 1868. 4 ACUTE CATARRHAL LARYNGITIS. 269 perfect phonation. This condition, as Gerhardti points out, is often caused by palsy or paresis of the thyi-o-arytenoid muscles, and indicating, as it does, an early change m the nerve supply of the intrinsic muscles, has a deep physio- lof^ical import. Although the elementary character of this treatise prohibits the discussion of this suggestive topic, it may be remarked that the derangement of motor function often precedes the superficial hypertemia, which from being a more striking feature is apt to be regarded as the earliest expression of the inflammatory state. The alteration of the voice thus early brought about points unmistakably to^ an interference with the innervation of the region as the initial step in some cases of ioflammation. But whatever hypo^ thesis is ultimately adopted to explain the phenomena ia question, the fact that " the longitudinal, and perhaps also the transverse tension of the vocal cords is iucomplete, and probably also unequal," is regarded by Ziemssen, with whose opinion I entirely agree, as a probable explanation of the "huskiness, jarring, and shrillness of the voice," which characterize the early stages of the disease. In very severe cases oedema may occur, and rapidly give rise to a serious stenosis. This condition will be referred to under " oedematous laryngitis ; " but it may be here remarked that acute catarrh of the larynx is, in the majority of instances, a superficial and transient affection, which under suitable treatment generally ends favourably iu the course of a few days. If neglected, however, it is likely to pass into chronic laryngitis, and is occasionally the starting jjoint in the forma- tion of papillary growths and other neoplasms from the mucous tissue. Pathology. — Catarrhal inflammation of the larynx consists in a hypersemia of the vessels of the mucous membrane. It may be either active (/.e. fluxionary) or passive. In effect it causes a reddening of the mucous membrane, together with an increased succulence of the eiDithelial layers, and a correspond- ing excess of secretion, consisting for the most part of a watery fluid containing imperfectly developed epithelial cells. The Avascular turgescence increases the lateral pressiu'e on the walls of the vessels, and causes changes in their intimate structure. At first only the plasma of the blood exudes, but soon an emigration of colourless corpuscles takes place. In 1 "Handbuch der Kinderkrankheiten." Tubingen, 1878, Star- Band, 2te Hfte., p. 322. - Op. cit. 270 DISEASES OF THE THROAT AND NOSE. inflammation of moderate severity, these migratory cells dis- appear with the hypertemia, but when the inflammatory pro- cess is more persistent they become organized and converted into lymphoid tissue. These lymphoid degenerations will be a^ain referred to under the head of " Chronic Laryngitis. Sometunes, beyond a sodden condition of the mucous membrane, there are no pathological phenomena. 11 the Datient die from other cause, on post-mortem examination the hypertemia is frequently not discoverable, and this is often the case when the congestion during hfe has assiuned very considerable proportions. The probable explanation of this anomaly is to be found in the rich endowment of the mucous membrane of the larynx with elastic hbres, the contraction of Avhich in artimlo mortis removes the engorge- ment of the capUlaries by pressing out their contents. Diagnosis.— A due consideration of the foregoing condi- tions i)oth objective and subjective, should leave little room for doubt as to the nature of the affection, except perhaps m the case of very voung children. In catanh the symptoms, thoucrh they may remit, do not pass off so completely as in laryngismus. In diphtheritic inflammation, i.e., true croup, the symptoms are much more severe, and there is often the presence of false membrane in the pharynx. In the absence of the latter phenomenon, the absolute necessity lor confirming the diagnosis by laryngoscopic inspection where it can be accomplished, is evident. The possibility of a foreign body having entered the aii- passages must not be pto W.-This is always most favom-able. MHd cases of catarrh pass off in a few days almost without treatnient and those of more severe character usually quickly yield to '"""^r^trnZ^-I^ the case of adults, the patient should be kept in a uniformly warm atmosphere, should employ warm and soothing inhalations, such as the benzoin, hemlock, or hop inhalati°ons of the Thi-oat Hospital Pharmacopoeia and should abstain altogether from using the mice and from takmg food or drink of an irritatmg character A compress to t e neck often arrests an impending attack, or cuts short the Tease at its inception. Diaphoretics piay be ad— wTiPTi there is anv fever, and a purge is often usetui at tne rSt. If hrie'is an; disposition to cough, the patient I 3d be kept slightly under the ^f-^^^^^^;^"^^^^^^ drinking of warm milk mixed with an equal quantity ol ACUTE CATARRHAL LARYNGITIS. 271 alkaline mineral water, as soda or seltzer water, is mucli praised by German authors. Though empii-ical in origin, like the proceeding sanctioned by Niemeyer of allowing the patient to eat very salt herrings, there can be no doubt that ■carbonate of soda and common salt _ exercise a solvent effect upon mucous accumulations, and it is doubtless from this cause that rehef attends their administration. In those rare cases in which there is htemorrhage from the larynx, a :strong astrmgent, such as tannic acid {3ij. ad §j.) should be ^applied to the bleeding spot. In a case of this kind Dr. Smyly, of Dubhn, on one occasion immediately arrested the hsemorrhage by the apphcation of Euspini's Styptic. When the disease begins to pass off astringent solutions such as the zinc and iron "pigments" of the Throat Hospital Pharma- copoeia are often very serviceable. In the case of children, a moist atmosphere maintained by the generation of steam is always advantageous. By this means the drying of the secretion during sleep is averted, .and the alarming attacks of dyspnoea, due to this cause, are warded off. As in the case of adults, a warm com- press to the throat often acts very favourably, and a hot sponge over the sternum is a time-honoured remedy in these cases. As young children can seldom use any apparatus which requires any effort in inspiration, the warm sooth- ing inhalations already mentioned should be emjaloyed by means of the croup-tent (see page 167) and the " ventHat- .ing croup-kettle," or with the aid of some other similar arrangements. Opiates are sometimes required, and their tendency "to dry up the mucus" is best obviated by administering the remedy in the form of the compound tincture of camphor, and by combining it with squills. At the same time non-depressant emetics, such as sulphate of zinc (grs. xv. to grs. xx.), or sulphate of copjaer (grs. v. to ;grs. vii.), in plenty of warm water, may occasionally be .requh-ed. In catarrhal inflammation of the larynx I do ■not recommend the application of remedies with the brush, bi:t Gibb,^ acting on the suggestion of Horace Green, em- ployed solutions of nitrate of silver (grs. xl. ad and stated that according to his experience one or at most two applications. of this salt usually suffice to subdue the local inflammation. This treatment has been recommended by .other English practitioners, and lately also by Professor ' •" Diseases of the Throat." 2nd edit. p. 197. 272 DISEASES OF THE THROAT AND NOSE. Stoerk.l lu my own practice, however, the results following the topical application of this salt have not been ^-^^^l^f ovy and I have-seen the whole train of symptoms g^efy aggi-a- vated by its use. Stoerk 2 further recommends that catairhal aryngitis should be treated by the internal and external use of ice. Leeching, bleeding, blisters, mercury and antimony the sheet-anchor^ of our predecessors, are remedies quite ou of date in the treatment of the disease, and cannot be put in the balance agamst our modern methods. J>>orZlaxis-ln the case of children who possess a spedly vrerable mucous membrane, such as may be in- heri ed from phthisical parents, certain measure should be adopted to diminish the susceptibility to catarrh Ihe tst of tese, perhaps, consists of tepid spongmg .vitk s.lt vvater on risii^g in the morning, followed by friction to. the entt^ body. Judicious clothing, especially the wearing of flannel next the skin,- should be enforced, and the adoption ■ of r aula out-door exercise insisted on. Great care should be taken to avoid over-heated sittmg-rooms or bedrooms M suable seasons a residence at the seaside, ^or^^^V^ ^^. of sea-bathing, will generaUy prove beneficial ^^^^^ ^^^^^^^^^ rhildren and old people, the mmeral waters of Koyat, taJcen fjiiy and Augit, ^atly diminish the in the succeeding wmters ; wlidst f or adults, the waters oL Mont Dore have a simUarly favoui-able influence. CEDEMATOUS LAEYNGITIS. (Synonyms : Labyngitis Phlegmonosa. Lartkgitis Suf- MUCOSA PuRULENTA.) j^^ii^ iJg.-aSdema acuta laryngis vel glottidis. Laryngitis phlegmonosa. . , , French j:.i.-Laryngite a^d^mateuse. CEdkne aigu de la Gennan ^J^.-pS^gmonbse Kehlkopfentziindung. Oedem der Glottis. Glottisoclem. Italian JJg.-Laringitide edematosa. Edema acuto della laringe. a uKlinik der Kranld.elten des KehUcopfes." Stuttgart, Enke-, 1876. ■i Ibid. (EDEMATOUS LAIU'NGITIS. 273 Definition. — Acute infiltration of the areolar tissice of the larynx hy a serous, sero-p'urulent, or j^urulent fiuid, charac- terized in severe cases hy orthopnoea, stridulous breathing and dysphonia or aphonia. ■ Histoi'y. — The descriptions of ancient authors, founded as they are entii'ely on the symptoms observed during life, and expressed in terms usually vague and often confused, do not point to this disease with any degree of certainty. The observations of Hippocrates,^ Ai'etceus,^ and Celsus^ are equally applicable to laryngeal diphtheria, Avhilst those of CaeUus Am-ehanus * and iEtius ^ specially point to the plastic form of inHammation. In 1765 Morgagni^ first gave a correct account of the conditions founded on post-mor- tem examination, and subsequently Boerhaave 7 and Van Swieten^ accurately described the cedematous character of the inflammation. These latter physicians did not, however, distinguish clearly between pharyngitis and laryngitis. Gradually medical writers became quite familiar with the malady, and in 1801 Bichat 9 described it with considerable ■detail, although since he speaks of it as " a particular kind of •serous swelhng which does not occur in any other situation," it is evident that he did not understand its pathological re- lations. In 1815 the various jshenomena of oedema of the larynx were first scientifically portrayed by Bayle,io and from his writings we may date the commencement of the literatiire of the subject. Previous to 1852 numerous papers of more or less importance had appeared in medical .joiunals, especially in France, but it was reserved for Sestierii in that year to collect these and found upon them a standard treatise containing a vast amount of statistical evidence. _ Etiology.— T\i& origin of the disease has been so minutely investigated by Sestier that it is impossible to do justice to the subject without largely making use of his laborious re- searches, which have reference to no less than 245 cases,i2 ^ l'PrEedict.';i.m. ^L.l.cap.Yi. 5 u * I^- iii- cap. ii. 7 « ^'^f^'".I«':P'«^-" l.v. c. 21. 6 " De Sed. et Caus. Morb." « u ^P^orisnu de Cognoscendis," &c. 801, 802. .0 .< h'^; ? ^r-^'J'f.T-" ' " Rescript." t. ii. p. 399. xraite de 1 angine laryngee oedemateuse." Paris, 1852 274 DISEASES Oil THE TUEOiT AKD S08E. exclusive of cases of scal.Uhroat. It ™st n^t ho,vovev, that certain fallacies are P/^™' "V^^, ' j^, i, wliich cannot therefove f »J V X c^nio and =f S "o? ^ a'vo aTlLlS '''SS'ce of age and sex ^r. before d^'^^^^X n e^C I"! thirtyive. SL\Te:r«^^l:rr:.ne antHoi. noted, in 1ST adults, 131 men and 56 women Acute o^clematous laryngit s may ^^^^^^ ^J^^^ secondary, that ^ suffering from persons, or may affect those pie ^ ^^^^^^ some other compla.^^^^^^^^^^ 190 ca^^^.^^ ^^^^^ , • , structures of the larynx. pxtremely rare. The Typical (Edematous laryngihs ^^^^f^^^^^^ady heen statistics of f :kntn^^^^^^ shown in the last article, that ^^t'™ a mild affection of the mucoiis ^l^^'lll^^^^^ According mucous areolar tissue is very httl concern ^^^^^^ .^^ to Sestier si^Pl^^^^^^f^frHs cases. I heheve that in rather more than 6 per cent. J.?^ inflanunation " nearly all these instances of ^o-caUea i ^.^^ the cHsease is due o Wood-poi^^^^^^^ ^ ^^^^^^^^^^^ ^^^^ affection amongst ^^ospj^tal pl^5 « ^^^^^^^ , l^e nurses, and in :^i;\\^tveircaBe that has come under its cause. I may add that m ^J^^J . ticeemia has been my notice, ample °Pr;:^^;^^V^^^ ^° f,,^ of (Bdema p/esent. Sestier's ^^^^^^^^^^^f^^^^^^ that acute cBdematous iring out P^ommently anotWac^^^^^^ ^1^^^, inflammation is a very me ^^^^^y o ^.^^^^^ ^^^^^^ out of the 245 <=ases oiJy ^xce cli^^^ ^^^^^^ ^ primary f-^2us\flammat^^^ occui-ring amongst adult, simple cedematous ^ ^Q^^an. fourteen were men, ana oniy on (EDEMATOUS LARYNGITIS. 275 Contiguous cedematous laryngiti,s', though I'tive in itself, is the most common ' form of the disease. Propagation most frequently takes place from the pharynx, and was found in more than 20 per cent, of Sestier's cases. Out of fifty-six instances where the disease originated in simple inflammation of the pharynx, it occuiTed thirty-one times in persons pre- ' viously healthy, and twenty-five times in patients convalescent or sulfering from some other affection. In Sestier's statistics there Avas not a single child among the patients previously healthy, but there were two children, between the' ages of foiu" and six years, amongst those already suffering from other diseases. The greatest number of cases occurred between twenty and fifty years of age, and the affection was twice as frequent amongst men as women. The pharyngeal inflammation was in many cases moderate and even slight, but the oedema of the larynx generally super- vened dmung the height of the faucial inflammation.^ It is highly probable that many cases of contiguous oedema are of an erysipelatous nature, though it is often diflacult to determine whether the disease is a true phleg- masia or an example of collateral oedema. As a sequel to diphtheritic inflammation of the fauces, acute oedema was only noticed by Sestier three times in his 24.5 cases. Contiguous redema rarely commences in the trachea and ascends to the larynx, Sestier 2 having only been able to find two very doubtful cases. Sometimes it follows aneurisms of the aorta or vessels of the neck, and in these cases it appears to be due to chronic inflammation of the cervical tissues, not to obstructed circulation. Consecutive cedematous laryngitis almost ahvays results from disease of the cartilages or perichoncbium, but it may follow any deep-seated or extensive ulceration. Acute oedema not unfrequently occurs as a secondary phe- nomenon. The acute diseases in which it is most apt to occur are smaH-pox and typhoid fever, hut it is occasionally met with in scarlet fever, and BoeckeP has published a case supervening on ecthyma. It may occur during the pro- gress of chronic tubercular or syphmtic inflammation 01 the larynx, though alironic redema is a much more trequent sequel of these conditions. It is also occasionally lound in post-scarlatinal dropsy, and sometimes in Blight's ' Op. cifc. pp. 70 and 71. ^ Ibid. p. 99. . =• " Annales des Maladies de rOreUle et du Larynx," vol. i. p. 387. 276 DISEASES OF THE THROAT AND NOSE, disease. Dr. PauveP has, indeed, pointed of J^^^ acute oedema of the hxrynx may be the first Byn;pt°m o renal disease. This form of secondary oedema has f « J^^/^; ^.f ^ J by Gibb3 and oth^rs.^ It must, however, be very laie in Sigh -s disease, arsome years ago at ^^7^^ .^rSma Pximined 200 cases of this complamt without finding ffidema S t^ itynx S a single instance. In the same way it is Lldom Ssent in general anasarca, and from the rarity of t rDeai?nce in this condition-a condition m itse f so its appeaiance i intervention of a phleg- rr^t&y^^^^^^^^ or neighbouring tissues is neariy always "^necessary" The same argument applies to ^i!;Si;r-The prominent symptom of cedematous l^yn- dt? the araduaUy increasing impediment to respiration Tbe iat ent°at first experiences the sensation of a foreign iody ?n tt Loat, aiid, after a short time^ ^.^f^^^ of Whiiig, which ultimately thi^eatens suffocation. At tL samXne deglutition is rendered more or less diflicul accoXVto the Wmtof sweUing of the ePJglottjs, and Te vdce oTadually becomes weaker and altered m timbre until .t last it is almost extinct. There is not, generaUy r^iinV any cou^h or expectoration, properly so-caUed, the tot '»'y/"t^'„jJ'Sl\?„Uy diste^^^^ Inspiration open, and gasps foi ^i^^J^^- ^ J ,^ith an intense con- and his whole ^fyf:^J^^'^^:,^S,iter a tune com- ^nir^rf^becLrof^^^^^^^^ hue, and, if natiu-e or 1 '< Aphonie Albuminurique." Rouen, 1863. 1863, vol. ii. p. 277, and 1864, Feb. .7. 4 Op. cit. p. 123. CKDEJIATOUS LAEYNGITIS. 277 art does? not afford immediate relief, deatli raj^idly occurs from asphyxia. Physical examination of the part may be made by the finger or by the laryngoscope, but the latter alone gives reliable information. If the finger is passed into the throat great gentleness must be exercised, as otherwise we may produce a dangerous suffocative paroxysm. ^ The epiglottis may be felt to be very much thickened, and the ary-epi- glottic folds may have attained such a state of tume- faction as to convey to the finger an impression similar to that which is given by touching the tonsils. ^ When the laryngoscope can be used the aspect of the parts is very characteristic. The colour of the mucous membrane is generally bright red. The epiglottis has the appearance of a semi-transparent roll-like body or ridge, or, losing its normal contour altogether, it presents two round red swellings pressed against each other. It is often merely erect and tense. It is this condition of the epiglottis which explains the pain and difficidty accompanying the act of swallowing. In many cases the swollen epiglottis blocks the view of the interior of the larynx. Occasionallj'-, however, the ary-epiglottic folds appear distinctly as two translucent folds, which almost meet over the entrance to the larynx, and often touch each other in the median line at each effort of inspiration. It rarely happens that the vocal cords themselves are infiltrated, but a case of tliis kind has been reported by Eisch,^ and I have twice met with a similar condition ui tertiary syphilis. Sometimes the cedema is limited to that part of the larynx which is below the level of the vocal cords. This form of oedema was first accurately described by Gibb,* under the name of "subglottic" oedema, though Sestier ^ and Cru- veUhier^ had previously made some allusions to such a condition. In these cases there is generally no swelling above the vocal cords. I have met with many examples of sub-glottic cedema, but they have all been of a chronic character. Pathology. — On close inspection of the cedematous larynx in the dead subject, the physical appearances of the part as "Clinique Medicale," t. iii. art. "CEd^me de la Wotte. ^ Krishaber : "Diet, des Sc. Med." vol. ii. p. 618. 3 " Berliner Klin. Wocliensch." 1866, No. 33. * Op. cit. p. 211. ^ Op. cit. " " Anat. Patholog." t. i. 1. ii. pi. ii. fig. 1. 278 DISEASES OP THE THROAT AND KOSE. ■viewed during life vith the laryngoscope are confirnied, whilst the pathology of the condition can he accurately determined. Where death has resulted from the axlema, the fluid collected in the sub-mucous connective tissue is generally of a serous character, but it may be sero-purulent, or even healthy pus. In the latter case the pus is always difiused, circumscribed abscess never occurring as a sequel of acute inflammation of the larynx. Pure serum is found only m the most acute and rapidly fatal cases ; as a rule the effusion is of a sero-purident character. Occasionally blood is found in the tissues, especially in those cases which have run a rapid course.i On cutting into the diseased parts usuaUy but little exudation takes place, and sometimes even squeezing between the fingers does not suffice to cause the disgorge- ment of the O3dematous structures. As the morbid process so often extends from the pharynx, the brunt of the inflam- mation often falls on the epiglottis, and this valve _ is Occasionally found enormously tumefied. But as the effusion collects where the areolar tissue is most lax, ^^^^ folds are the parts which are most frequently distended, and in which the swelling attains its maxunum. iNext m ire- quen^ the ventricular bands sufter, whilst the vocal cords mav be slightly tumefied, but are rarely swoUen to any Ttent In very rare cases the (Bdema can be traced down tS trachea to'the commencement of the Ijonchr. The muscles are frequently saturated ^-^l^/^);; ^^^^^^^^ ^J^^ patient survive the acute stage and die from o^her cau^^^^ the parts previously oedematous present a sodden and shniXen appearance' In contiguous oedematous laryngitis the m^chboiing structures are more or less impkcated m he nSrbid process, and the -Uular tissue of he ^ tonsils, soft palate, uvula, and even of the neck, is otten retronharvn^eal abscess, and foreign bodies m tlie iarjnx retropnaiyuocci povpfiil practitioner from falling a Sestier: Loc. oit. ; alsoPfeufer: « Henle u. Pfeufer's Zeitschnft fiir rat. Med." Neue Tolge. Bd. m. OiDEMATOUS LARYNGITIS. 27'J the observer, hut the presence of false membrane, Avhich can generally be seen in the pharynx or may be coughed up in shreds, determines the diagnosis. Any disease which gives rise to dyspnoea, such as aneurism of the aorta, narroAv- ing of the trachea, cervical tumours, &c., may simulate cedema of the larynx, but the history of the case and the laryngo- scopic examination will generally fm^nish conclusive evidence as to the real nature of the malady. Prognosis. — Except in slight cases, or where the oedema is partial— affecting one ary-epiglottic fold or one side of the epiglottis only — the prognosis is extremely unfavourable. Even when local measures have removed the obstruction to free respiration, the patient is very liltely to perish subse- quently from exhaustion, or blood-poisoning, or from pneu- monia or other lung complications. Dealing roughly with the literature of the subject, Sestier^ found that the affection proved fatal in 158 out of 213 cases in spite of tracheotomy having been performed thirty times. In the fifty-eight cases which recovered, the trachea was opened twenty times. Bayle,^ however, gives much less favoiu'able figures, for he reports seventeen cases with sixteen deaths. Secondary cedema is more fatal than primary. The prognosis also depends on the kind of oedema as well as on the age and sex of the jjatient. Typical cedema is almost always fatal, whilst the contiguous form generally does well, if the inflam- mation starts from the pharynx. It is, however, invariably fatal when it spreads from the neck or chest, as in the case of aneurism of the aorta or of the large cervical vessels, and nearly always so when it commences in the external areolar tissue. In consecutive oedema, the local affection being almost always at the same time a secondary phe- nomenon, the prognosis depends on the nature of the original disease. In typhoid fever it is very unfavourable, whilst in phthisis the condition is in itself comparatively unimportant, . and in syphilis it usually yields to treatment. The affection is more serious in men than in women. According to Sanne, in the former four-fifths of the cases prove fatal, and in the latter only three-fifths. The same author states that the greatest mortality (in proportion to those atfected) occurs between ten and thirty years, when eight-ninths of the cases prove fatal. ^ The next highest mortality is between fifty and .seventy, whilst the maximum power of resistance appears to ' Op. cit. p. 241, et seq. ^ Op. cit. 280 DISEASES OF THE THROAT AND NOSE. be between thirty and forty and forty and fifty, in which two decennia, about one-half of the cases, according to Sestier, prove fatal. i i. i • Trefl/?7^«^^.-Prompt local treatment nrnst be adopted m order to remove the laryngeal obstruction. Local bleed- ing, by means of leeches placed over the sides of the larynx, is often of considerable service, and in mdd cases may elfect so much reduction in the cedema as to render the subsequent progress of the case free from danger ihe inhalation of pidverized liquids, especiaUy of a solution ot tannin as recommended by Trousseau,^ may also be tned Ica should be uninterruptecUy swallowed, and the patient should be kept constantly under the influence of bromide of potassium. It will usually, however, be necessary to carry out some more decisive measures Scarification, hist practised by Lisfranc,3 is often successful when the disease is drcumscribed. Tliis operation may be performed by means of a long, sharp-pointed bistoury, covered, except for the last quarter inch of its length, with adhesive plaster or lin*- Jf^^ best instrument, however, for the purpose, is the la yngeal lancet (pacre 253). A primitive method of scarifying the larynx Ss" practiced by Legroux,3 lacerated the mucous membrane with one of the finger nails ^l^^^^^^^'^^l^^^ to a point for the purpose. After scarification garghng with warm water aiuf steam inhalations will --^'Honts the expidsion of fluid from the tissues. 1^ ^-f unavaUin- we must have recourse to tracheotomy and it is to perform this operation early, than to wait until an aMo^t moribund condition of the patient renders surgical interference nearly hopeless. Traumatic Laryngitis. Violent inflammation of the larynx, jS — areolar tiss„ ^ from corrosive poisons, or lium ^ i '"'Sa of am larvnx are frequently met^ ^ith amongst seldom seen except wueic x-.HoJ-i'' x- 1 Loc. cit. , „ lao-^- "Mem sur I'Angine lar. oademat." 2 " Journal de Med. 1823 . ap,,t 1839 3 " Joum. des ConnaisB. Medico- Cliir. Sept. IbJJ. TEAUMATIC LARYNGITIS. 281 described by Dr. Marshall Hall.^ and subsequently by Stanley,^ Burgess,^ Wallace/^ Kyland,^ and Liston.^ At a later- period Jameson^ reported seA^eral cases, and more recently Bevan.s Eoss," Jonathan Hutchinson.^o Parker,ii and others have recorded instances of the accident. These scalds are indeed far too common at aU the general hospitals, and when I was Eesident Medical Officer at the London Hospital,, many cases came imder my notice. Children allowed to drink tea from the spout of the tea-pot, unaware of the danger, occasionally attempt the same feat with the boiling kettle. Instant inflammation of the pharynx and orifice of the larynx sets in, and in two or three hours, or even sooner, the epiglottis becomes greatly swollen and oedematous. The age of the patient usually renders the use of the laryn- geal mirror out of the question, but the fauces shordd be illumi- nated as in laryngoscopy. Under these circumstances the erect and oedematous epiglottis can often be seen at the hack of the tongue. Scarification is the most rational method of" treatment. If the proper laryngeal lancet be not at hand, the oedematous parts may be incised or punctured with a gum lancet, or a curved, sharp-pointed bistoury, protected by strips of plaster to within two or three lines of its extremity. Non- dej)ressant emetics may be given either before or after scarifi- cation, the pressm-e wluch the act of retching exercises on the oedematous tissue favouring the effusion fi'om the ruptured,, or punctured, mucous membrane. Scarification, fairly and fully carried out, ought to supersede all other treatment, and is much to be preferred to leeches and mercurials. Tracheotomy may be had recourse to as a last resort,, though it cannot in these cases lay claim to the success which attends its timely performance in ma^iy other cases of laryngeal obstruction. Laryngitis from corrosive poisoning is generally of a very Adolent character, and is freqiiently followed by gangrene- Tracheotomy is often caUed for. Laryngitis from the pj-esence of a foreign body can oidy be- relieved by the extraction of the offending substance. The sudden swelling which takes places in some of these cases- 1 "Trans. Med.-Chi. Soc." London, 1822. 2 Ibid. 3 "DubUnHosp. Eeports," vol. iii. « "Lancet," March, 1836. I Op- cit. (i "Lancet," 1839 & 40, p. 103. "Dublin Quarterly Joum." Feb. 1848. » Ibid. Feb. 1860 "Medical Press and Circ." 1868. i" "Lancet," Feb. 1871 " Ibid. May 1, 1875. •282 DISEASES OF THE THROAT AND NOSE. partakes of tlie cliaracter of venous obstruction, such as may be artificially produced by tying a piece of stnng tightly round the end of the finger. The rapidity-often on^y a few minutes, or even seconds-with which the tumefaction takes place, far exceeds anything that can be accounted for by inflammatory action. Should it not be possible to effect the removal of the foreign body, tracheotomy must be performed if the symptoms are at all urgent. ABSCESS OF THE LAEYNX. (Under this head abscess of the larynx dependent on perichondritis is not considered.) Latin jEg.— Abscessus laryngis. French ^g.— Abces du larynx. German J5Jg.— Abscess des kehlliopfes. Italian i:*?.— Ascesso deUa laringe. Definition.— 4 circumscrihed collection of pus due to damnation of the soft tissues of the larynx, ^nterfer^n^ with the vocal functions of that organ, and sometimes with the proper action of the epiglottis. Etiology. -Th^ causes of the disease are the same as those which give rise to diffused inflammation of the larynx. The Iffection is extremely rare, and generaUy occurs m an acute Wom^-Dysplxonia or apl^«"i^' ^^^P^Xch^L^^^^^^ .sionaUy dyspncBa are the ordinary symptoms Wl^^^l^ Tmost involved depends on the exact seat of the affection. opened, it is extiemeiy hklij^ rpsults ^ I sime cases it bursts spontaneously, and a cuie results. 1 " Laryngoscopie." ^e^^' ]f ^f-' P', ^ iQo et sen. ^ - KeUkSpf krankheiten." ^^erbn 1861,^P- Jb-^^^^^^^^^^ 3 Schi-oetter : " Klinik fur Laryugoskopie, J ahie^beiicni. 1870, p. 15. ABSCESS OF THE LARYNX. 283 have myself met with, tliu'teen cases of idioiDathic abscess of the lai-ynx. In six cases, the abscess occurred at the root of the epiglottis; in four, in one of the ventricular bands ; and in three iustances, one of the ary- epiglottic folds was the seat of the disease. In most of my cases the symptoms were very severe : in nine the abscess was opened with a laryngeal lancet, and in four the abscess biu?st. All the patients recovered. Diagnosis. — It is very difficult to diagnose this affection with certainty, for as there is generally a considerable amount of inflammation around the abscess the appearance is that of an acute inflammatory swelling. Sometimes, how- ever, the abscess actually points, and the yellow colour of the pus can be detected through the mucous membrane. As Professor Bruns i has pointed out, this yellow colour is the only certain laryngoscopic sign of abscess, but sometimes the disease may be differentiated from oedema by the swelling being less transparent in the former case. Prognosis. — The prognosis is generally favourable, if the abscess has not attained a very large size when it first comes under treatment. In pre-laryngoscopic times the disease has been reported to have been quickly fatal in several cases. Dciring ^ recorded a case in which a soldier died on the third day from an abscess at the base of the epiglottis. Treatment. — If the abscess is small it should be imme- diately ojaened with a laryngeal lancet, and if it has spread towards the skin, the opening should be made externally. In the case treated by Eiihle, already referred to, a fluctuating tumour was felt with the finger, at the upper ajserture of the larynx, and there was a swelling over the left ala of the thyroid cartilage. After using an exploratory needle an incision was made externally, and a cupful of pus was evacuated. The patient was cured in a few days. K the abscess is very large, tracheotomy should be performed, and after Dr. Semdn's tampon-canula (see Tracheal Instruments) has been inserted, the abscess should be oj)ened in the ordinary way. ^ " Laryngoscopie." Tiibingen, 1873, p. 132. = Ruble : Op. cit. 84 DISEASES OF THE THROAT AND NOSE. CHRONIC LAEYNGITIS. (Synonym : Cheonio Catarrh of the Larynx.) Latin ^(Z-— "Laryngitis chronica. French i;g.-Laryngite clironique „ German i^.-Clu-onisclier Catarrli des Kehlkopts. rtnlian iJf/.— Laryngitide cronica. T)EFiNiT ON JGhronic inflammation of the Ivni^O memlran. UaA to j^i, ,j.„u„„ tto same as effects of eonttatty o text™ are oto s » m alcoholism and tlie 'f 3, jnechanicaUy supposed that elongation '™ "r" , "J^ an almost iir tating the epiglottis and orifice ot ^'^^ 3^,,„i certain cause of chrome ^'2lt"Aa.\^Z togSher ,-ith cases ■-^-'^tT:^Tti^ ^^^°m^^'-^^^ P™''--"' some congestion ol '"'yfH„„„,t„j| '^,^1. the affection or at least maintained, by f /™Sf ^ ""'i^ had been ^"^"ytifoiXthl f'am iLlLd to agree .itb snipped ott , but on tut w . mj^tion liasljeen Ziemsseni that the ^^l^f ^^f^T ^ o^^^^^^^^^ observing that greatly overrated, and that E^^^^^^ , , tX'i:^^^' cause-chi-onic ^'STStence of an atn^spl^ ^^^S^^ matter, in the P^-^l-^^^J Vv f C.dn^^^^^^ ^'^'-^ 1 " nvcloTDffidia of Medicine," yol. IV. . ugL Sucopfkranldif en.- ^^^^^^ jo^.'' 3 « Dissert. Inaugur." &c. iialte, K , vol. xcviii. p. 4. Trranldieiten der Kiinstler und Hand- ii. p. 27. OHRONIO LARYNGITIS. 285 time, HoUand/ Heussinger,^ Vircliow,- Lewin,* Headlam Greenliow,5 and other physicians have liu-ther elucidated the subject. It need, therefore, only be observed here that the larynx suffers in common with the rest of the respiratory system in the case of needle grinders, pearl-button turners, and others who work in an impure atmosphere, the chronic form of catarrh being especially common amongst persons so occupied. The great and sudden development of the larynx which takes place at puberty in males is often attended by chronic laryngitis, the so-called "cracked voice" of boys being always associated with marked congestion of the vocal cords. There seems also to be a rare constitutional con- dition, where there is a tendency to chronic inflammation of many of the mucous canals. Seven such cases have come under my notice, all the patients being men over fifty years of age. I had at one time a gentleman under my care who was suffering from chronic laryngitis, slight thickening of the walls of the lower third of the oesophagus, gastro -intestinal 'derangement, and chronic cystitis. The influence of age and sex is very marked in cases of chronic laryngitis, adult males being by far the most common sufferers, and children the rarest. As a secondary phe- nomenon chronic laryngitis is, of course, almost invariably present in all long-continued diseases of the larynx, such as phthisis, syphilis, polypi, cancer, lupus, &c. Symptoms. — The subjective symptoms of chronic laryngitis vary considerably under different conditions. AVhen the patient refrains from using his voice, the local sensations are not very marked, some dryness and irritation in the throat, with occasional tickling cough, being all that is complained of. If the patient, however, exercises his voice for any length of time, these symptoms become much aggravated, and he is soon obhged to seek relief in silence. In some cases, in addition to the symptoms above mentioned, ^ ' ' Diseases of the Lungs from Mechanical Causes, and Inquiries into Conditions of Artisans exposed to the Inhalation of Dust," by Dr. G. Calvert HoUand. London, 1843. • "Ueber anomale Kohlen- imd Pigmentbildung. " Eisenach, 1823. ' ' ' Anatomische Beschreibung der Krankheiten der Circulations- und Respirationsorgane." Leipzig, 1841. ■* " Beitrage zur Inhalationstherapie in Krankheiten der Respira- iionsorgane." Berlin, 1863. " " Chronic Bronchitiij." London, 1870. 286 DISEASES OF THE THROAT AND NOSE. a burning or pricking pain is felt, and there is often a frequent desire and cifort to clear the throat. Obiectively, the phenomena of chronic laryngitis consist in a marked alteration of voice and a slightly increased secretion, and in certain definite anatomical changes, im- pau-ment of the function of the larynx is the most charac- teristic symptom of the disease. It varies m degree from slight modilication in tone to complete loss of voice. it is characteristic also of this form of hoarseness m the early stacje, that it is most marked when the organ has been at rest for some time. Thus, a patient with shght chronic congestion may be extremely hoarse on attempt- in- to speak after an interval of silence, and yet the voice wSl become almost normal after the function has been exercised for a few minutes. The improvement probably depends on the quickened capillary cb?culation and stimu- lated nerve-force of the part, and has its analogy elsewhere. If however, the patient continues to talk for a time, fatigue is 'experienced, and hoarseness or aphonia supervenes, in chi-onic laryngitis the voice is sometimes clear and natural in its ordinary tones, and the discordance is only observed when powerful exertions are made (as m singmg acting, public speaking, &c.). The cough is generaUy rather frequent, but it may amomit to nothing more than "hawking, or "hemming," and sometimes it is almost entirely absent. In some cases, however, it constitutes the most troublesome '^frS'arcls secretion, the expectoration is never abimdant, unless the laryngeal affection be complicated with bronchitis. The mucus discharged from the larynx is generaUy of a whitish-grey colour, and of viscid consistency, but ni Tases of long standing it is yeUower, and after violent Txacerbations^of coughing f-^^^f ^ ^IJ^^^^^^^^^^^^^ blood Respiration is seldom much affected, but moist rales ■ ran ^eneraUy be heard over the larynx. , ■, , ^ TfX?4«cop'« appearances are usually very marked but varv con iderably in different cases. A general or partial hy- ™k invarilbly present. The redness is generaUy suffused and f?des off gradually into the healthy-coloured membrane,but infect' on of the minute vessels is sometimes apparent, especiaUy on the epiAottis and vocal cords. On the former the injection is Sual Wborescent, on the latter the arrangement of the vessels SoLtimes one vocal cord is seen to be bright red, whilst the CHRONIO LARVNGITIS. 287 other is of the usual white colour, and the congestion may even be limited to a small portion of one cord. In the latter case it is always the outer attached portion of the cord which is con- gested. Small pellets of mucus are often seen sticking to dif- ferent parts of the laryngeal membrane ; and in cases of long standiiig, the whole surface of the larynx is frequently covered with secretion. In some cases the mucous membrane, instead of presenting the velvety appearance which generally accom- panies any pronounced congestion, looks dry and glistening. General tmnefaction of the; mucous membrane and sub- mucosa is a very pronounced feature in inveterate cases, the epiglottis, ventricular bands, and inter-arytenoid fold aU participating in a diffuse and uniform thickening. In jihe case of the vocal cords this change sometimes causes a granular condition of their surface, and often a very perceptible uneveuness of their edges. Derangements in the mobility of the larynx may often be noticed. Some of these phenomena are of a mechanical nature, and depend on muscular action being clogged and impeded through the thickened state of the mucosa and sub-mucosa. Thus the hypertrophied inter-arytenoid fold prevents the normal approximation of the arytenoid cartilages and vocal cords ; while the swollen ventricular bands sometimes almost obHterate the ventricles of Morgagni, and encroaching on the vocal cords, materially impede their movements. In addition, however, to these mechanical effects, true muscular pareses of peripheral origin are often present ; in such cases, as Ziemssen ^ observes, the paralysis is more often unilateral than bilateral. Where only one cord, however, IS paralyzed, the impaired movement is made up for by increased activity on the part of its feUow, which is dragged across the middle line, beyond its usual range of movement. By this means approximation and phonation are secured, and in such instances obliquity of the closed glottis can be seen with the laryngoscope. Erosions, or very fine shallow ulcerations, which ex- tend no deeper than the epithelial layer, are not unfre- quently visible. Then- most frequent seat is between the arytenoid cartilages and on the cartilagmous portion of the vocal cords. Ulcerations, which pass through the whole thickness of the mucous membrane, are of very rare occur- rence in this affection, and perichondritis is very seldom met with, except in the subglottic regions. ^Loc. cit. p. 216, 288 DISBASKS OF THE THROAT AND NOSE. In addition to congestive B^elling of the n— sulD-mucosa, tliere occurs m some ^^^^ J^^^^^^J^"^^ °The thickening or hypertrophy of the soft epiglottis ventricular h^^^^^ and ary ej^^^ occasionally affected m tins Avay. . , f^lds in noticed the to^^^^^^ of the jry ^^^^^^^ preachers. He attributes it jj^uscular fascicuh contamcd m the „ hollow tones which express recessary to proctace *ejeep ho^^^ ^^^^ ^ ^^^^^ pathos. I . -^"f' *SSly rare tMs eovmtry except ary-epiglottic folds s ''^^'T^^l^ i^^^ii fold is far more ii^rfy^Srnodr excrL^^^^^^ the res.lt o, ciic iiiiammation are oi>^n met ^J^. PoiMoW.-Tte disease is jf'f {J ^^a, the zfaui —rot the -".tre^rtri^ LSCrt-:;Sth\^^^^^^^^^^^ - superacial erosions seen during life. . i "be formed hy Diagnosis.-An accurate opimon (^^^ g^^t import- careful laryngoscopic examinatiom^^^^ L^'^itis to ohserve anoe in every case of ant^hi cLdi^^^ exists, to whether tl^-e is t^^^^^^^^^ tumefaction, determine whether it is . deposit. In simple CBdematous infi tration, ^^^^J^^J^^^^^ parts is almost chronic laryngitis, the J^f ^^^^^^^^^ l^.J^t redder than always preserved, but tW^^^ - S-^^^^ ^ that of health. ,^^f^Xracteiistic transparent loright colour, and has a characie ^^^^^ ^s,,aUy in phthisis, on the other ^^^^^^^^^^^^^^ ^ccidentaUy con- ofiduUcolour, hough he smtace^^^^^^^^ ^^^^^^ gested ; the swelhng also as a i^U^ P ^^^^^^ ^^^.t Uate forms, which 7^^^^ -^^^^^^ of some months' disease. In aU cases «f .^^^^^^^^^ cai^f ully examined, the standing the lungs mu ^« ^ ^^^^f closely investi- !^Srattth\ nature of the di^^^^^^^^ 1 «Vircliow"sArcluv. Bel. xxiv. p. CHRONIC LAKYNGITIS. 280 Prognosis. — The tendency of the disease when once fully-established is to remain stationary, or the symptoms may disappear for a short time and then recur. Under per- sistent local treatment and the carefid avoidance of the exciting causes of the affection, however, recovery can generally be secured. In old people the malady is always complicated with chronic bronchitis, and the symptoms of the latter affection mask and outweigh in importance the morbid phenomena dependent on the chronic laryngeal disease. Chronic laryngitis hardly ever terminates fatally, almost the only possibility of sucla an occurrence consisting in the supervention of perichondritis, and such an issue is excessively rare, except when the disease occurs in the sub- glottic region. Treatment. — Local remedies of an astringent character are the most important agents in the treatment of chronic laryngitis. Any of the following " Pigmenta " (Throat Hosp. Phar.) may be used : — Ferri perchlor. (60 gr.), ferri persulph. (60 gr.), ferri siilph. (120 gr.) cupri sulph. (10 gr.) zinci chlorid. (30 gr.), zinci acet. (5 gr.), zinci sulph. (10 gr.), aluminis (30 gr.), alum, chlor. (60 gr.), dissolved in an ounce of water or glycerine. The latter solvent, through its denser consistency, is better adapted for keeping up • a prolonged action on the part. Solutions of the crystals of nitrate of silver were strongly recommended by Green i in follicular cases, but they do not seem to me to act more beneficially than other mineral astringents. The solution of chloride of zinc is the remedy I most frequently employ; but provided the medicament is applied accurately and sufficiently often, it really matters very little which solution is used. The application should be made daily for the first seven days, on alternate days during the second and third week, twice in the third week, and so on, at gradually increasing intervals till a cure is effected. This is a general rule, but It must be modified according to circumstances. In cases where there is excessive secretion from the larynx (laryn- gorrhoea), the local application of turpentine sometimes does good, but these cases are generally very troublesome to treat. _ On the other hand, when there is long-standin^r fiyperamia, with diminished secretion— Avhere the mucous membrane looks dry and shining— the remedy which I iiave found most successful is carbolic acid (from half a ■• "OnBroncHtis." New York, 1846. U 290 mssiSEa of the tdhoit asd Kobe. di-aehm to a drachm of tU pm-o white eavMic acid to an "Tlof applying astringent -Intions larynx consists in tho '^f^Z:S^tZ?^r:T':Tu, ^:%:S:SrLnt bdnrP»l=ahly host of alU =o„, given a. ^^1^^" Tannin, 1 to 6 f;/^™: „ i to 6 gr ; chloride of zinc, wt£tv°^ 0tatL'°is sdected, it shonld be ^^l^rt^ttsH Tried r pareses oj the -'tl^SISetrrtroSLe t^t the v.. jonld . f hVhet ht'^S^ntated. ' As"h. pha^nx is rSt;2ht ^nore . ^^^^ iS SS^lTH^^^i/^nXIplSs^^^^^^^^ in this fo™ with great advantage „ .^^,^,^1,^^, Ems, and Selters are The waters of O^f^-^ f Xme^er.^ ^dio observes tliat especially f co-^^^^^^^ ^emS fa^ts that these waters must accept ^^^^^^^PJ^'f ,^,oi,ic laryngeal catarrh Z^i' :Clsoli? .ith gr.an«.x. . '.I,to..ci d,r Spec. PatW. T1«"P ." CHRONIC LARYNGITIS. 291 Several patients whom I have sent to the Pyrenean springs have derived nndoubted benefit from the use of tliose waters, but, on the Avhole, I have seen more benefit result from the waters of Aix-les-Bains and Marlioz. The climate of the Pyrenees is sub-tropical, and generally very ennervat- ing in its effects on English patients. I can particularly recommend the hot sulphur-waters of Savoy when the voice remains weak and the mucosa is relaxed rather than congested. AVhere suitable atmospheric conditions cannot be selected the patient must wear a respirator, when the weather is at aU cold or damp, and must protect the neck and body generally by -warm and suitable clothing. Constitutional medicines and hygienic treatment Avill be necessary, in some cases, and must varj"- according to circumstances. Chronic Glandular Laryngitis. This condition consists in an inflammation in which the minute racemose glands are principally affected. It is almost always associated with follicular pharyngitis,^ of which malady it generally constitutes a downward extension. It cannot, however, be called "follicular laryngitis," as the glands of the larj^nx are all of the racemose variety (^olliker). The term "clergyman's sore throat" has been apjDlied to it, but the clergy more often suffer from congestion of the whole mucous membrane and pareses of the laryngeal muscles. Although usually resulting from a previous pharyngeal affec- tion, it sometimes commences in the larynx, and afterwards reaches the pharynx. It is often associated -with indigestion, but whether there is any causal relation between the two conditions is uncertain. The symptoms are the same as those of simple chronic laryngitis, but perhaps milder — weakness of voice, fatigue after speaking, a constant inclination to clear the tliroat and §wallow the saliva, or perform an act of degluti- tion, being the principal morbid phenomena. With the laryngoscope the enlarged orifices of the glands may some- times be seen on the epiglottis and the posterior parts of the vocal cords as pale specks on the congested membrane, or as small red circles on the pale membrane. The other laryngeal appearances do not differ from those of simple 1 For a full description of this afEection see " Granular Pharvn- gitis," p. 28. 292 D1SBA.SBS OF THE THBOAT AND NOSE. laryBgitis, except that the WO--ative act^^^^^^^^^ cords k more often feeble and ^;|;P-f^^^^ XU, fo'r considerable constitutional debility. J^^e tioatm^^^^^ larvnsitis, the most part be the sa.e as for ^^^^^^ tut nitrate of silver (S^ -^^^^J^J Aix-les-Bains are =Sly%Xtble &utio.al remedies of an analeptic character are also generally required. Phlebectasis Laryngea. persons affectecl w^^^^^^^^ ^l^^^P^ ^ venous system (iiasse;, 01 . ^ ^-^^ ^ems is Ducheki considers that the dUatation ^^^^^^^^^ ^^.^ one of the aggregate results oi om meet "with phle- probably a mistake, seeing how ^^^^J^^^'i itis. As a Ltasis and ^^/XSon c.^""^ eng^r|ement of a sequel to ^T^Tv^ith huUwt venous W^i^^^^ passive character is often met . g^me alteration ance. The symptoms are g^^f^^^^^,^^^^^^^ and, perhaps, in the voice, an uneasy I'^^'^X^^' ICl^noii^fmovm a more or 1- ^^^^^^^^^^^^^^ mlj be thus phenomena. J^^J^f Xe the disease is very Umited, described :-Wd ^^^^^^^^^ ^^^^ rimning_ along the extremely fine daik ^^^^^^\^J-r~ epiglottis. In more upper border of the ven^^^^^^^^ ^i^^ibution of the severe cases there is less le uiai y . yentricular distended veins, whicW^^^ Cases have bands, -r\TnX^^^^^^^^^^^^ """" come under my notice m wu , £ var cose veins- adhering to the larynx ^^l^^l'^^^Xiohe.yoM. This an error which needs '^t^Zl^llj of the inconvenience condition of the l^^^n^, rnd^P^^^^^^^ danger, as it it occasions, is probably ^ttenclea ^^^^^ Astringent most likely Pf ^^^^I'^'J'Jeo^y treatment calculated to solutions may do good ^^^X^,,tru.tion of the veins effect a permanent cure consists m electric cautery. ; - I ..Traitede Pathologic interne,' vol. i- CHRONIC LARYNGITIS. 293 Trachoma of the Vocal Cords. Yery important organic lesions of the vocal cords are some- times produced in persistent cases of chronic laryngitis. Amongst these a roughness of their suiface, apparently arising from a partial dermoid metamorphosis of the mucous mem- brane/ is not unconuuonly seen. This condition has been called chorditis fuherosa ^ or trachoma of the vocal cords, _ and appears to consist in a hypertrophy of the connective tissue and a proliferation of its nuclei.^ I have met with it most frequently in the case of singers. These cases are often extremely obstinate, and sometimes defy all treatment, but generally a prolonged course of local remedies of a strongly astringent (Ferri Perchlor. 3ij. fid. gj.) or caustic nature (Argent. Mt. 3j. ad in the end effects a cure. Sub-glottic Chronic Laryngitis. Chronic laryngitis in the sub-glottic region sometimes gives rise to considerable tliickening of the tissues, especially at the under surface of the vocal cords. When the disease is well established the tumefaction often presents the appearance of a second vocal cord immediately below the true cord. Occa- sionally there is, so to speak, an interruption in the swelling, so that the projection can be seen below the vocal cord for a certain length, then a clear space, whilst further on the sub- cordal swelling is again apparent. The colour of the hyper- trophied tissue is generally whitish-grey, but it is occasionally red; the surface too, though usually smooth, is in rare cases more or less ulcerated. Hoarseness is the first symptom of the disease, but complete aphonia generally occurs at a com- paratively early period. Dyspnoea is also perceived as soon as there is any considerable amount of thickening, and attacks of nrgent suffocation sometimes occur. This symptom, as Catti-"' has pointed out, results from the vocal cords becoming at parts agglutinated together by viscid mucus. Eokitansky ^ was the first to discover and describe this condition, and Czermak " shortly after published the details of a case in which he diagnosed the affection in a scrofulous girl by means of the ' "Traite de Pathologie interne," vol. i. 2 TUrck : " Klinik der Krank. d. Kehlkopfes," &c. Wien, 186G Wedl. Ziemssen : Loc. cit. * "AUgem. Wiener Med. Zeitung." 187S. No. 39, u.f. 5 Jahi-b. d. Path. Anat." iii. Aufl. bd. iii. § 16. ■,",P.'r'^ Kehlkopf Spiegel und seine Verwerthung. f. Phys. und Med." 11. Aufl. Leipzig, 1863, ^87. o j 294 DISEASES OF THE THROAT AND NOSE. larvncoscope Tiircki jn^blished a case in 1866 and Scheff^ aryn oscopo i F Schroetter^ reported three cases and in 1873 Gerhardt^ described the disease under^he .mnc of Chorditis voccdis inferior ^^P^^'f^^^ traTeototy BW has pnhlished ^^^^ ^1:^1^^^^ ZT!t ToWe^-eTatcS for a condtoL tin.e, and two only ief crawly In l.e former tracheotomy was found neces- a y iTe h stance. Other practitioners have also recorded =L hnt the most important article on the subject is that Sy wr tttbrMessor Schroetter^ which contains a good Ssumrof our present knowledge of the disease. rrsidemble doubt exists as to the exact nature of thi. atfSk^n though in some cases the patients are of marked ""^ M^ui^^^^^^^^^ The immediate local cause gene IJni m-)nears to be persistent inflammation of the mucous f iSrand the siumg differs little tan ^' h^ tl^P mter-arvtenoid fold and posterior wall of the larynx so tntntlY met with. Sometimes, as Schroetter points out, he'Ti^cLrseems to originate in the -til^^^^^^^^^ chondrium, those structures being most ^J^^^^^^^^^^^^^^ pitliPr iust below the anterior commissure of the vocal corab, nr, +W innerlurface of the sides of the cricoid cartilage- , aer Krankheiten des Kehlkopfs nnd der Luftrohre. ^f^^Sned. Presse," No, 51, M 31^^ ^i,,, 1871; ; 'iSf^^^z^SlS^' de/L|fS^^^en.'> Wie., .873. :.?KatsschriftfurOhrenheilkunde,''&c. No. 12. 1878. : der Krank^eiten des Keldkopfes." H.dfte. i. Stutt- gart, 1876. CHRONIC LARYNGITIS. 295 «ul)-"lottic region no doubt often takes place in the form of blennorrlio3a just referred to, yet, on the other hand, it is •certain that it very frequently occurs quite independently of that affection. Schroetter, with reason I think, objects to the term " chorditis vocal is inferior hypertrophica," inasmuch as it locahzes too narrowly a pathological condition which may affect any part of the larynx. Eokitansky considers the disease as an indurative metamorphosis of the mucosa and sub-mucosa. Sub-glottic chi-onic laryngitis is not so rare as is generally supposed, for between 1864 and 1872 nineteen cases came under the care of myself and colleagues at the Hospital for Diseases of the Throat, and I saw four cases at the London Hospital.! In every instance the disease was confined to the sub-cordal region, having been unilateral in sixteen cases, and bi-lateral in nine. But were I to include cases in which the inter-arytenoid fold was affected, together with the posterior portion of one or both of the vocal cords, I should be able to mention many more cases. In five of the twenty- three cases the sweUing was partly translucent, and hence, no doubt, to some extent cedeniatous, but in the remaining eighteen it appeared solid. When once the disease is fully established there is no •difficulty in distinguishing it, the only question which can arise is that which has reference to the density of the swell- ing. In the cedematous cases the sweUing is generally round in outhne, resembling a nasal polypus, and can scarcely be mistaken for the more substantial form of hypertrophy. In aU sub-glottic diseases the prognosis is relatively miicli more unfavourable than where the affection is supra-glottic. We see this in the case of benign growths, in oedema, and in cicatricial contractions. The difficulty of treating disease locally in this situation is so enormously increased that the more unfavoiu"able prognosis will be readily intelligible. The prospect of the patient may be inferred from a brief reference to my twenty -tlu-ee cases. In three of them Mr. Evans performed tracheotomy (1866), whilst in the previous year I opened the trachea in two cases referred to me by Dr. Patrick Fraser. Subsequently, between 1866 and 1872 (inclusive), I performed tracheotomy in five other similar ,L°f ■• phthisis was present in three other or B^lfVrSff "l^*'^^';^^ cedema spread from an inflammatory or purulent point external to the larynx. ^ ,, 298 DISEASES OF THE THROAT AND NOSE. NON-MALIGNANT TUMOURS OF THE LAEYNX. (Synonyms : Benign Gbowths in the Larynx. Polypus OF THE Larynx.) Latin Polypi laryngis. Fvpncli K(7.— Polypes du larynx. Grli(i.-La?ynxpol^ Italian Eq.—'^oYxiA della larmge. DEFiNiTioN.-i\^.../or™«^/ou. of henign Inn m-olections on the mucous membrane of the lai ^nx, ZIS%0 rise to aphonia or dysphoma, often to dys- pnoea, and occasionally to dysphayia. msfory.-Isolated cases of lai-yngeal P^^yP^^^.^f tlie year 1750/ being one 01 lu undoubted years later LieutaudJ pnb^^^^^^^ ases ;J laryngeal polypus^ In 1833 to ^^^^ ^ , to remove a growth by {^'^y^^J^"^^^ laryngeal growth which, included 31 ° ^ 10 additional cases ; 1851.^ Eohitanslcy J^^^^^^^^^^ ^ori.. published r9'c:is!'2'o? whiSh had occurred in his own practice. Methoderdes'enservirponr F^^^^^ ^^^^ Figux-es." Ala la Matrice, en forme de Lettre a ii^.^ ^^^^^ by Lewin: Have, cliez G-oese ^^'^'t-oq isfi-2 Deutsche Mar^^ 29. ^862 2 " Historia Anatom. mea. u.u. 3 CiSd by Ehx« See Note 6). ^^^^ 4 u Osservazione C^uig. J^c- ^ ^^^^ larynx and 5 "A Treatise on the Diseases ^^^^ j Trachea." , _ , Tini-vnx." Strasbourg, 18.50. 1852. " Transactions ot the ivmeiiou-u NON-MALIGNANT TUMOURS OP THE LAUYNX, 299 In the following year Dr. Gurdon Buck collected 49 cases, including his own interesting example ; and in 1854 Middeldorpfi brought together 64 cases. Finally, in the year 1859, Prat published a case in which he had removed a growth through the thyro-hyoid membrane.^ Amongst all these cases there are only 9 in which an attempt was made to remove the growth during life, and one of these, viz., that by Koderik, already referred to, is so vague, that it must necessarily be excluded. On the invention of the laryngoscope, laryngeal growths were investigated with great zeal, and cases were soon pub- lished by Czermak,-^ Lewin,* Gibb,^ Fauvel,^ Walker,7 and others. In 1865 Professor von Bruns^ issued a monograph containing 17 cases, and in the following year Dr. Louis Elsberg^ published a prize essay containing 13 cases. In 1868 von Bruns^^ reported 23 additional cases. In the year 1871 I published a work containing 100 consecutive cases operated on by myself (from 1862 to 1870), and 189 other cases — being all the cases reported up to that time in medical literature. Here I may, perhaps, be allowed to observe parenthetically, that I have since operated on 123 other patients (from May 25th, 1870, to December 31st, 1878). The conclusions, as regards the etiology and natm-e of the growths drawn from my second series, being almost identical with those derived from the first set, I have not thought it necessary in this article to alter the various percentages formerly arrived at. I may mention, however, that owing to the more careful exclusion of malignant disease, the results, as regards the restoration of voice and absence of recurrence, have been more favoiu-able in my recent cases. In 1872, Stoerk'- published 36 cases operated on (1871 and 1872), and in 1874 Tobold " reported 206 cases, with 70 operations (between 1861 and 1874). In the same year ^ "Die Galvanokaustik." Breelau, 1854. ^ " Gazette des Hopitaux." 1859, No. 103, p. 809. •* " Wien. Med. Wochenschrift." January 8, 1859. ■* " Deutsche KHnik," 1862. * " Diseases of the Tliroat." Second Edition. " " Du Laryngoscope au point de vue pratique," 1861. I' Lancet," November, 1861. 9 '/ J^^^ ^'^ryngoskopie," &c. Tubingen, 1865. in Growths within the Laryu<." Philadelphia, 1866 Polypen des Kehlkopfs." Tiibingcn, 1868. _ ".'rowths in the Laiyiix " London, 1871. - • Laryngoscop. Operationen " Wien, 1871-72. Laryngoscopie." BerUn, 1874. 300 DISEASES OP THE TIIKOAT AND KOSE. Schnikleri ,ecorded 35 cases operated ^fl"^^ fll 1874). In. 1875 OerteP ^'^'^-'if ^^^^^ ^ t 1875 were operated "Ml-etween 1862 and ^^^^^ "-It^^^^^^^^ cases, 48 of wh w^^ J^^^^^^^ (from 18/0 to lbl6). ^^^l-. . -ioykn Xn the Les. Witt 18 oi.evat.»« 18Y» ^ 18 5). thpotomy. riHS article, and includes the cases already leteirea lo m n > besides 200 cases OP^^-^^^^^^^^J J^^^^^"" /sn §78 35 cases operated on hy M Biuns (lb membrane is, lai auuvL, ci ^j^^tin-n nf simnle morbid OTOwths m tiie larynx. inflammation, but " " «TfrlU a^^te Sack Llu«tly leads to the jEmia, that tne muie d common cause ot production of a forma^^^^ The m st^_^ ^^^^ hn^ercemia IS probably catairh a ^^^ ^^^^ ^^^^^^^^ be looked upon as ^^e geat p 1 constitutional Neither syphilis, nor phthisis, nor any 1 " Med. Presse." Wien, 1874. ^ WESe: ,376. ^ ^ 6 ''Traite pratique des maladies du Laiyax ^^^^^,1,, Med. 6 « Deutsche lOinik," Nos. 33-41, 18<*, Woclieiisclirift," No. 34, 1°;% intra-laiyngealer Neubil- " "Die LarjTigotome ^^'i"^'^^^^ ^^e of the original work, dungen." Berlin 1878 ™«* ,„.^eis, by Dr. Felix Semen I have also Wed myseH of an exc r" Medical Exammer, may a- ' ^ 8 . 'Medical Becord," February 9 878. " Ohio Med. and Surg. Journ. 18-8. NON-MALIGNANT TUMOUBS OP THE LARYNX, 301 condition, appears to favour the development of true growths, hut hoth these dyscrasite — especially the tuhercular — give rise to false excrescences or inflammatory out-growths. In cases of phthisis these formations, when present, occur at the posterior part of the larynx— generally on the inter-arytenoid fold. When a very protracted syphilitic congestion occui-s, growths may arise; hut this is a rare exception, and Dr. Harlan has well pointed out that few true laryngeal growths can be attributed to syphilis.^ The fact, to be shortly referred to, that the affection is occasionally present at birth, makes it probable that a congenital predisposition to the disease may sometimes exist, though the neoplasm is not actually formed till adult or middle life. Some of the exanthemata, especially variola, scarlatina, measles, and erysipelas, lead to the production of laryngeal 23olypi, by giving rise to chronic inflammation of the lining membrane of the larynx. The professional use of the voice is one of the circum- stances most favourable to the development of growths, 21 per cent, of my patients old enough to have an occupa- tion having been subject to this influence.^ Dr. Tobold^ remarks that the affection is most common in middle life, from the thirtieth to the sixtieth year, and that laryngeal polypi are least frequently seen in child- hood. Dr. Causit,''' on the other hand, considers that they most frequently occur in early infancy. The latter author, indeed, believes that the disease is very often congenital. But this mode of origin, though very probable in many cases,^ has only been actually established in four, viz., one recorded by Dufours,^ two cases in my own practice,7 and one, the most important of all, reported by Dr. Ai'thur Edis.8 In this case the child died from suffocation thirty-seven hours after hirth, and a cyst about the size of a hazel nut was foimd in the larynx. According to my ex- perience, the middle period of life would appear most ^ "American Journal of Medical Science," vol. lii. p. 122. - "Growths in the Larynx," p. 16. ^ "Die chronischen Kehlkopfskrankheiten." BerHn, 1866, t) 200. , , i>. * " Etudes sur les Polypes du Larynx." Paris, 1867. = Paul Bruns considers that there are at least twenty-three cases on record in which the afEection was congenital. (Op. cit. p. 177 ) "" Archives Generales de Med." Mars, 1867. ' " Trans. Path. Soc." vol. xxv. p. 36. 8 " Trans. Ohstet. Soc." vol. xviii. p, 2. 302 DISEASES OF THE THROAT AND NOSE. favourable to the development of these neoplasms and I Ld that after the age of fifty there is a considerable and sudden diminution in their number. In ^^^ ^^^^^ in mv own practice, the decennium of forty to fifty furnished tL greatest' number of cases, whilst there were as many a seventy-two between the ages of twenty and fifty. On the other hand, there were only three patients over ixty. I have latelv removed a papilloma from a woman aged seventy rwhose Lse the sym^toL of the ^^^<^^^on ^^ orAj exas^ed +1.0 . Vint the o-reatest age at wnicn a giowin ha^^beerst^oclted Vthe practice of Dr. Bruns, who met with a case in which the patient was seventy-foui- "^Ts to'L causal influence of sex, of my 100 patients 62 ^ete males and 38 females. Of 187 paWs the practice Tf other operators, 135 were males, and 52 female . Svnwtoms.-lt will be readily understood, that, as a rule the sS and symptoms of a growth in the arynx depend Mf nature 01 the exact situation, and on the size on the natiue on ^ ^^^^^ ^^^.^^^ ^^^^^^^ fphtiaTh a?^^^^^^^^^ on the ep^ottis l^^od-^^^^ dyspSa^^^ ; and a large timiour, wherever situated, is likely ine luii^^^" ° ■, , J experience of such cases. Jn,^v couX and the paroxysmal dyspnoea, the presence of croupycough, ana J .^^,,,,1 by the experienced a g™^^;^ J^;y J ^^'^'3^3 ,^1,0 Lve not met with many laryn- laryngologist but those > ^ ^ ^.^^^ ^^^^j^ geal polypi J^^^;^73 f tten, however, that many ^^i' ^^^^^ cartilage. voice though not invariably present,. An alteration m ^^^J^^rn^ a growth in the larynx, is the most ^^-^^^^fZ.te .^s impaired ninety-two- I, niy 100 a^^^^^^^^ 1,3, ,oice in fifty-five cases, r^o».thi^y--^^-^^^ t ^i^SCa^a by I small growth often 1 Op. cit. : Cases xv. xxix. NON-MALIGNANT TUMOURS OP THE LARYNX. 303 interferes "with vocalization more than a large one ; for the small neoplasm, being almost always sessile, greatly modifies the vibration of the vocal cord to which it is at- tached, Avhilst a large one often becomes pedunculated as it groAvs, and by rising up into the cavity of the larynx, interferes very little with the normal formation of sound. Growths on the epiglottis and ary-epiglottic folds do not generallj' affect the voice, unless they attain a very large size ; and the same is not unfrequently true of small neoplasms on the ventricular bands. Growths below the vocal cords, on the other hand, by diminishing., the column of air passing through the larynx, or by being forced up into the glottis in expiration, often cause aphonia. Patients with laryngeal growths do not, as a rule, suffer much from cough • but this symptom is occasionally so severe as to cause very great inconvenience, and it may even give Tise to htemoptysis. The character of the cough depends upon the size and situation of the growth; it is generally dry and hacldng, and often aphonic. In young children, and in adults when the growth is very large and situated in the neighboiu'hood of the glottis, it has often a croilpy cliaracter. In seven out of the twenty-six cases noticed by Dr. Causit it was described as " croupal." I have seen it occur also in two cases in violent paroxysms. Dy.spncea was present thirty times in my 100 cases, and was serious in fifteen cases. Difficidty of breathing occui-red in about the same percentage of the cases reported by other prac- titioners. ^ Most of the specimens of laryngeal growths in the metropolitan museums were taken from patients who died from suffocation ; and in nearly all the cases reported in the medical journals before the invention of the laryngoscope, dyspnoea Avas a prominent symptom. The difficulty of breath- ing is often paroxysmal. The explanation of this circumstance, as in many other cases of laryngeal obstruction, is, that the patient is able to breathe weU, even through a narrowed wind- pipe, provided that no further diminution suddenly occurs. If, however, the patient takes cold, and the mucous membrane becomes a little swoUen, a paroxysm of dyspnoja may super- vene. In the same manner, if the respiration be hurried by exertion, an attack is Hlvcly to come on. Sometimes, also, dyspnoea occui's suddenly, from the patient getting into an unusual position, and from the growth being consequently thrown more across the glottis. In one of my cases 2 the ' Mackenzie : Op. cit. : Appendix D. Ibid. : Appendix A, Case 84. 304 DISEASES OF THE THROAT AND NOSE. patient could only sleep with the hand resting under the neck ; and if by chance her head slipped away during sleep, she immediately woke with a severe attack of dyspnosa^ It almost invariably happens, that inspiration is much more difficult than expu'ation, and Lewm has remarked, that the character of the respiration has a certain diagnostic value, as regards the seat of the growth. When inspiration is noisy and stridulous, and expiration comparatively easy the growth is probably situated above the vocal cords, and vice versa. . , . . . ii „ According to my own experience, actual pam is seldom caused by growths in or about the larynx, but uneasy sensa. tions are occasionaUy felt. In only one of my 100 cases was there decided pain, though m another^ there was a sensation of oppression. Though patients rarely complain ot a feeling of a foreign body in the larynx, they frequently have a disposition to clear the throat, as if to expel some accumu- lated mucus. I have most commonly met with this symptom ill cases of pendunculated growths, especiaUy when they were attached to the vocal cords. , ^ ^+ Difficulty of swaUowing does not generally occur, except when the growth springs from the epiglottis or where it attains a very large size ; it is occasionally 7' when the neoplasm arises from the arytenoid _ cartilages. In Biy 100 cases dysphagia was only present eight tmies, and in every instance ^ the epiglottis was the seat of the disease. In one case only ^ was there odynphagia. The physical signs are much more important than those of a ftmctional character, and amongst them those observed with the laryngeal mirror stand pre-eminent. So complete is the formation furnished by the laryngoscope, that were I not that there are certain rare and exceptional cases in wh?ch th Sument cannot be employed the general TemeioloV would be useless. The situation of the growth can aZost always be ascertained with the mirror, but in a few c^es wto the growth is very large, the exact seat o^->.gm t Jponcealed The vocal cords are especiaUy hable to riffectedThte parts having been alone attacked in seventy- foii of my cases, and suffering either alone or m conjunction 1 " Deutsche KHnik." 1862. 2 Mackenzie : Op. cit. Appendix A, Case 97. 3 Ibid. : Case 90. * Ibid. : Case 83. B Ibid. : Case 28. NON-MALIGNANT TUMOURS OF THE LARYNX. 305 with other parts in no less than eighty-five cases. On the other hand, the arytenoid cartilages, with their folds of mucous membrane and secondary cartilages, enjoy comparative immunity. The laryngoscopic appearance can best be described in •detail, by separating the different kinds of tumours, accord- ing to their jjathological nature. Fcqnllomata (Figs. 54-56) are generally sessile, though occasionally pedunculated. They are often multiple, and j^Kj. 54. — Papilloma m a Child mi. eight. Pig. 55. — Solitaey Papilloma, m an Abult. Fig. '56. — Multiple Papilloiia in an Adult. sometimes occur symmetrically.^ They vary in size from a grain of mustard to a walnut, but they do not often attain the latter dimension. Their most common size is that of a large split pea. They are generally of a pink colour, but they may be Avhite, or even bright red. Fibromata (Fig. 57) are usually round or oval, but occa- ' Mackenzie; Op. cit. : Appendix A, Cases 40 and 80. 306 DISEASES OF THE THRO.VT AND NOSE. sionally arc of a very divided form, not luilike caiiliflower excrescences .1 They are generally, but not invariably, pedun- Fig. 57. — Fibeomata. culated Tlieir surface is usually smooth, but it may be rou"h irregular or wavy, and they are commonly of rather a bright red colour. They are almost always single, and vary in size from a split pea to an acorn. Miixomat.a (Fig. 58) are very rare. In the smglo cise 2 which I have met with, the neoplasm grew from tho Fig. 58. — Myxoma. vi-ht vocal cord, and was only in part of a mucous character ; this portion was seen with the laryngoscope to be qiute transparent, and of a bright pink colour. Fig. 59.— Cyst. Cjdie Tumours (Fig. 59) most frequently occur on the 1 Mackenzie : Op. cit. : Appendix A, Cases 78 and 97. Ibid.: Case 99. NON-MALIGNANT TUMOURS OF THE LARYNX. 307 epiglottis, or spring from the ventricle of Morgagm. They arc round eo-g-like projections, and, as they usuaUy rise to some local irritation, are themselves red, and are surroundpd^ a hvper;T[?mic area. ~f- u^U^^^ '^e/%^\xl» C-^-^yy^f^'*^, Amjiomata (Fig. 60).-The two growths of this kind which have come under my notice, were of a hlackberry-like Fig. 60. — Angiomata. appearance, in colour-, form, and size ; one grew in the right hyoid fossa, the other from the right ventricular hand. _ A similar urowth has heen ohserved in the former situation hy Fauvel.^ Lipomata. — In the only case of lipoma on record ^ the growth was hi-lohate, of yellowish-white colour, and had a memhranous pedicle, which appeared to project from the whole length of the ventricle. By means of the laryngeal sound the density, the size, and the exact origin of a growth may often he determined, when with the laryngeal mirror alone there is stiU douht as to these various points. A smooth growth may he either a fihroma or a Hpoma ; hut whilst the former does not yield to pressure, the fatty growth is soft and resilient. The appearance of a laryngeal growth in the mirror is frequently deceptive, and it is often only by moving it with the sound, that its dimensions can he at all accurately determined. This is more especially the case, from the fact that only one surface of the tumour is visible in the miiTor. Again, the insertion of a growth is sometimes hidden by the growth itself, and it is only by traction with the crotchet that the precise origin can be ascertained. The various kinds of sounds and crotchets which are useful are shown in Fig. 26. p. 243. Examination with the index-finger is of some value in ' Op. cit. p. 882. * Bruna: " Kehlkopfpolypen," p. 84. 308 DISEASES OF THE THROAT AND NOSE. those cases in Avliicli the growth is situated on the epiglottis, or the ary-epiglottic folds ; but it may give fallacious results/ and is seldom of any practical service, where the tumour is attached at a lower level. By pressing the larynx upwards with one hand on the thyroid cartUage, and by drawing forward the tongue with the other, the upper laryngeal orifice may occasionally be seen, and growths in this situation are thus some- times visible. Voltolini^ recommends that in addition to external manipulation and holding out the tongue, the fauces should be slightly irritated, so as to produce moderate retching. , ,, ,^ On auscultation of the larynx, when the growths are at all large, moist sibUant rales may be sometimes heard, but they°are only characteristic of laryngeal obstruction. When the larynx is blocked up with growths, a dull sound is elicited on percussion. SmaU growths, however, do not m any Avay modify the usual resonance. It occasionally happens, e^peciaUy in papillomatous growths, that small particles are expectorated, and, on microscopical examination, their nature can be verified. When this occurs in conjunction with other symptoms, it of course furnishes general evidence as to the nature of the disease ; and when there is aphonia at the same time, it may be inferred that the growth is m the neighbour- hood of the vocal cords. 1 1 4. --p In the early stages, the disease is purely local ; but ii the growth become large, it may, by embarrassing the respiration, or tln-ough other causes, give rise to constitutional disturbance; in this way, some amount of wasting and hectic may be caused, and these cases were formerly mis- taken for phthisis. Marked constitutional symptoms are, however, of exceedingly rare occurrence. The various symptoms aheady described generally deve op themselves slowly, taking many months for their evolution Theie . Always a difficulty, however, in fixing upon the com- mencement of the disease, because the hyper^emia, which generaUy precedes the growth of a tumour gives nse to the same phenomena as the neoplasm itself. ihe Iro'ress of the case depends, of course, m a great SSe, on the -pathological native of the neoph.m After attaining a moderate degree of intensity, the ^jmp toms often remain stationary, audit is surprising ho^^ long 1 "Gro^vtllS in the Larynx," p. 204. z " Berlin. Klin. Woclienschr." 1868, No. 23. NON-MALIGNANT TUMOUKS OF THE LARYNX. 309 some patients— especially among the industrial classes — will suffer from aphonia before they seek relief. In one of my cases the patient had suffered from aphonia for twenty-four years, and another from dysphonia for twenty-three years. On the other hand, if dyspnoea or dysphagia be present, the patient is soon obliged to apply for medical aid. As a curious fact recorded in medical literature, rather than as having any practical bearing on the course of laryngeal growths, it may be remarked, that there are a few instances 1 in which the disease has been cured by the acci- dental separation and expectoration of the entire neoplasm. Diagnosis. — The diseased conditions which might ^ be mistaken for. gTOwths, are those occurring in syphilis, laryngeal phthisis, elephantiasis, lupus, malignant tumours, and outgi'owths. Eversicn of the ventricle might also give rise to an error in diagnosis. The conchjlomata of syphilis are seen as irregular, whitish, very slightly raised prominences on the congested membrane, the posterior Avail of the larynx being their most common site. These formations are comparatively rare, and when present, generally occur from six weeks to three months after the primary inoculation ; they soon disappear under the use of mioeral astringents. False excrescences are the result of syphilitic ulceration and subsequent cicatrization, and occur as irregular jDrojections iu different parts of the larynx. The gummata, which are occasionally foimd in the larynx, are so evidently deposits in the tissues, that they are not hkely to be mistaken for true laryngeal growths. The thickening of laryngeal pJithisis has not the defined character of a true laryngeal growth, and is generally soon followed by ulceration. In the few cases of lepra that have come under my notice, in which the larynx was affected, the mucous membrane covering the epiglottis was uniformly swollen. I believe that the disease never attacks the mncous membrane until after it has shown itself on the tegumentary surface. The thickening of lupus is generally very much like that which occurs in tertiary syphilis, and is usually soon followed by destructive ulceration. It is not always easy to distinguish between benign and ^.malignant laryngeal growths; the latter, however, may be generally recognized by beiag more thoroughly blended > Paul Bruna and Oertel : Op cit. 310 DISEASES OP THE THROAT AND K08B. with the surrounding tissues, and by being very frequently ulcerated. In these cases, should particles be expectorated, or removed dming life with the aid of the laryngoscope, the microscope may afford useful information. Outgrowths, whether of cartilaginous, fibrous, or lymphoid character, are not likely to lead to mistaken diagnosis It true that the symptoms are often similar to those caused by laryngeal growths, but when the laryngoscope is used, the entire absence of demarcation between the protuberance and ti e normal tissues, in the case of outgrowths, is at once evident When seen with the laryngeal mirror, they appear rather as non-inflammatory swelhngs or infiltrations than as defined tumours. A very characteristic case of this sort, m which the outgrowth was probably of fibrous character, is contained in my Jacksonian Prize Essay.i Everslon of the ventricle is, perhaps, the only intelligible somxe of error, and this condition is extremely rare. I only know thi-ee such cases in the literature of medicine. Iwo ot these were only recognized on post-mortem examination but li a third Dr. Leffert's,^ of New York, at once diagnosed the "iZ^^^-^-ta are by far the most freqiient of all thfb growths in the larynx. In my 100 tabulated ases, sixty-^even were Judged to be of tins chai^cter^ Th crrowths occiu at an earlier period of life than the otlier Cds of tumours, nearly aU cases found in the first decennial- ''^'^t^^Ht^r^^ distinguish three varieties, which slw marked differences with regard to the -ten.1^-^^^^ between the operation and the recurrence. Ihe fiist class, cotrstin' of light-red or dark-red tumours, varying in size froTa millet seed to a bean, with uneven surface and broad X MS. and Coloui-ed Drawing in the Litoiy of the Boyal CoUege of Surgeons. „ qj. 3 Mackenzie: Op. cit. p. ^4- 3 " New York Medical Record. June 3,1b <0 4 " DeutBches Arcliiy fiir khn. Medizm, Bd. xy. p. -90. 5 Op. cit. NON-MALIGNANT TUMOURS OF THE LARYNX. 311 after several years. The third form consists of large reddish tumours resembling a midberry or cauliflower Ihey may be solitary but are most frequently midtiple, and are commonly seen in children. These growths generaUy recur after one ■ or two months, and in three or four instances have been known to undergo epitheliomatous degeneration. In esti- mating the circumstances wliich govern the recurrence of papiUomata, these differences, as well as the question, whether the papiUoma has been radically extirpated, are to be con- sidered. In several reported cases repeated recurrences took place at the primary seat of the growth, which was evidently incompletely eradicated, but ultimately a complete cure was . effected by the thorough removal of the new-grown papil- loma. There is also a class of cases, in which papillomata . appear, after removal of the primary tumour, on other, pre- viously healthy, parts of the larynx. These are not exactly recurrences, nor due to the operation, but simply show that • even complete removal does not afford any guarantee of permanent cure, if there be a tendency to the formation of papillomatous growths. Fibromata are of two kinds : (a) the firm and (h) the soft, . and the former are twice as common as the latter, (a) Firm fibromata, though not nearly so common as papillomata, . are next in order of frequency to those neoplasms. They were found to exist in 11 per cent, of my cases. The youngest patient affected was twenty-seven years of age, the oldest fifty-seven. In this class of neoplasm, the rate of growth is much slower than in the case of papillomata. Thoii Loc. cit. NON-MALIGNANT- TUMOURS OF THE LARYNX. 313- Other hinds of aroivth.— Adenomata, or glandular tumours, are seldom met with in the larynx, though acnious gland-structure is often found iii papillary groAvths 3^ occa- sionally, however, the entire neoplasm consists of an hyper- trophied racemose gland. It may perhaps be as we 1 to remark here that hydatids are stated to have been found m the larynx.-^ Eylaud^ states, that "a case of this sort, developed m one- of the ventricles of the larynx, has been known to project so far into the cavity of tliis organ, as to give rise to aU the symptoms wliich usually attend a foreign body there. On this- subject, Poerster observes,^ that " mucous polypi were described as hydatids, by the older authors." Eyland also refers to cases- of cartUaginous tumoius of the larynx ; but the examination of these giwths was made at a period (1835) wli^n histology was quite in its infancy, and the account, therefore, is not- of much value. Rokitansky does not mention the occui-rence- of cartilaginous tumours in the larynx, but Vircliow,^ limit- ing the term of Enchondroma to heterologous growths, and describing those cartilaginous tumours, Avhich arise in coiinec- tion with pre-existing cartilage, as Ecchondroses, especially calls attention to the occiuTence of the latter in the larynx, and remarks that, "whether arising from the thyroid or cricoid cartilage, they generally grew towards the cavity of the larynx." This is not, however, invariably the case, for in a specimen which I exhibited at the Pathological Society,^ a groAvth about the size of a bantam's egg, originating from the cricoid cartilage, extended do^vn-- wards and forwards ia front of the trachea. "The cartila- ginous outgrowths," saysYirchow, "are sometimes broad and flat, sometimes circumscribed and nodular. On examining the larynx (with the laryngoscope), an outgrowth of this sort, as it has an epithelial covering, is easily mistaken for a polypus, and at the present time, when laryngeal growths are studied "with, so much interest, these cases deserve-- special notice, as, from their thickness and hardness, any operation, carried out per vias naturales is altogether- ^ The reverse of this is stated hj Drs. Comil and Ran-vier in their useful little "Manuel d'Histologie pathologique," p. 289; but Dr. Andre-w Clark has repeatedly found portions of racemose glanda iu the gro-wths I have removed. 2 Andral: " Anat. Pathol." Translation, vol. ii. p. 459. 3 Ryland : " Diseases of the Larynx," p. 226. * Foerster: Op. cit. p. 210. 5 Op. cit. p. 438, et seq. » " Transactions of the Pathological Society," vol. xxi. p. 58. 314 DISEASES OF THE THROAT AND NOSE. impossible." Professor von Brims ' operated on two cases of laryngeal growth, in which the neoplasm was proved to ^consist of thyroid-gland tissue, tlie disease being probably ixUied to the so-called struma accessoria of Albers.'-^ Deqeneration of Growths.— 'Laryngeal neoplasms, with the exception of some very rare forms of papillomata, which may become cancerous, exhibit little tendency to retrogressive changes. Occasionally, but most infrequently, the papillary growths undergo fatty degeneration, and probably in those few cases in which spontaneous expulsion of the neoplasm has taken place, this change had previously occurred. Caustics may perhaps, in some cases, promote these degenerative evolutions. Sometimes the neoplasms undergo amyloid degenerations, and the cases of amyloid growth reported by Dr. Ernst Burow,3 and Ziegler,^ probably originated in this way. Prognosis. — The tendency to death being by suffocation, iind tlie most common symptoms caused by a growth in the larynx bemg dysphonia, the prognosis has to be considered in relation to these two cu-cumstances. In the few cases in Avhich dysphagia is present, the neoplasm is generally attached to the epiglottis, and can therefore be easily removed. Under these cu-cumstances a favourable prognosis may be given. (a) In relation to L//e.— Growths in the larynx Avhich can- not be removed with the aid of the laryngoscope are always .attended with danger to life, which is either immediate or remote, according as the neoplasm is large or small, ihe oravity of the prognosis is also affected by the age ot the patient, the disease being, cceteris paribtis, less dangerous m -the case of adidts than young chddren. In adults death is not lUcely to take place fi'om suffocation, unless the patient refuses to submit to proper treatment. Of course, if tracheotomy is performed, the perd of suffocation is at once avoided; but it must not be forgotten that even m open- incthe windpipe, there is a very slight, though stiU an appre- ■ciable risk The disposition to bronchitis, which is often the immediate result of tracheotomy, when prolonged dyspnoea has prevaHed, must also be taken into consideration. li cMclren, as the larynx is much smaller, the disposition ^Sho^T'^'&niU-eu'Geschwulste." Twenty-second Lec- "^"""""LarWoscop. Atlas." Stuttgart 1877. 1 Vii-cliow's " Ai-chiv." vol. xlv. p. 1- NCN-MALIGXANT TUMOURS OF THE LARYNX. 315 -to spasm is mucli greater, and not only treatment, but even accurate diagnosis, is much more difficult. The presence of a <.TOwth also predisposes to laryngeal affections such as catarrhal laryngitis, and possibly laryngismus Avhi st m the presence of epidemic diphtheria, the child with a laryngeal neoplasm is more likely to be attacked and less likely to recover. In children also the prospect m relation to trache- otomy, both as regards the operation itself and its immediate results, is less favom-able than in the case of adults, ihe prognosis, therefore, as regards a fatal termination, is more serious. . (h) In relation to Voice.— regards the voice, a favourable opinion may, as a rule, be given if laryngoscopic treatment can be employed. If the fances be not abnormally sensitive, if the upper opening of the larynx be of average size, if the <;rowth be single, and if it be pedunculated, there is every probability that the voice wiU be restored. If the opposite ■conditions prevail, the prognosis is less favourable. When the growths are sessile, very numerous, and apparently closely incorporated Avith the subjacent tissues, the prospect of restoring the voice is extremely doubtful. In giving an opinion as to the ultimate result of these «ases, even when treatment is adopted with success, the dis- position to recurrence must not be forgotten. In the section ■on Pathology, it may be seen that whilst some forms of papillomata show a continnal disposition to reproduction, ■other laryngeal gi-o^\^hs, with the exception of fasciculated ^sarcomata, seldom recur. Treatment — Before considering the subject of treatment, it may be weU to observe that there are a few cases in which ■operative proceedure is not required. Thus small growths ■on the epiglottis, or ventricular bands, which cause little or no inconvenience, may well be left alone. This remark •especially applies to hbromata, which grow much less quickly ■and are more frequently arrested in their development than ■other growths. In these cases, all that is necessary is to make -a periodical examination of the larynx, once or twice a year, to see that the neoplasm does not increase in size. Several cases have come under my observation, during the last twenty years, in which small warts, after attaining a certain size, have not undergone any further development. Further, it sometimes happens, that the neoplasm is not sufficiently defined to admit of its removal, and in some cases, where, in con- sequence of the advanced age or occupation of the patient, DISEASES OP THE THKOAT AND NOSE. the voice is of little importance, no treatment need be adopted i;nless the respiration be also affected. But before discussing the various kinds of treatment, it will be well to inquire whether any possible evil can result from endo-lai^ngeal operations. The principal points for consideration are the follow- in o- : — 1. Does the oi^eration ever cause such an amount of inflamma- tion as to necessitate tracheotomy ? 2. Does perichondi-itis or necrosis of the cartilages ever result from these operations ? 3. Does a benigii' gi'owth ever become malignant under the influence of laryngoscopic operations ? 1. Since I have taught laryngoscopy, many young practitioners have leamt to remove gi-owths under my supervision, and though of coui'se these early operations are often unsuccessful, I am not aware of a single instance in which any violent inflammation has been thus set up, or any serious injury done to the larynx. Cases, however, occasionally occur in which bad results may appear to follow laryngoscopic treatment. Thus a patient may ijresent himself with a large growth nearly blocking up the glottis, but with little dyspnoea. Now it must be remembered, that such a patient is^ in imminent danger of death ; a slight catarrh, a crumb of bread going" the wrong way, or a paroxysm of coughing may choke him in a few seconds. The question thus arises in these cases whether we should perform tracheotomy at once, and subsequently remove the' gi-owths by endo -laryngeal treatment, or whether we should try the endo-laryngeal method in the first instance. It must be clearly understood that, if the endo-laryngeal operation is not successful, it is certain to precipitate tracheotomy, and that a patient who, though on the brink of suffocation, might have postponed the operation for several weeks —possibly for months— may require to have his wind-pipe opened in a few hours or even sooner. Under such cir- cumstances the patient and his friends— possibly even the medical attendant if he has not carefuUy studied the peculiar contingencies of thecase— may suppose that the rashness of the operator has necessitated an extra-laryngeal operation which would not otherwise have been called for. On the other hand, if the operator had at once proclaimed the necessity of tracheotomy, he would have been free from blame in the minds of those looking on. Nevertheless the duty of the laryngoscopist, under the circumstances referred to, is clearly to try the endo-laryngeal method in the first instance, after fuUjr explaining the situation to the patient. I can recall many instances, in my own practice, in which tracheotomy has thus been altogether avoided— cases, indeed, in which I scarcely supposed it possible to- operate without being obUged to open the windpipe precipitately. In three instances, however, of large growths, in which endo- laryngeal methods were attempted, I found it necessary to perform tracheotomy a few hours— in one instance two hours— later. 2 As reo-ards the development of perichondritis, I am not aware of any instance in which this condition has resulted from an endo-laryngeal operation. In one of my cases, » m which the left vocal cord was immobile before the growth u-as touched, on the removal of the growth from the anterior commis- sure of the vocal cords, the abductive action of the left cord was seen to be defective, and four months later tracheotomy became » Op. cit. : Case 73. NON-MALIflNANT TUMOUBS OP THE LAKTNX. 317 -necessary After wearing the tube for eighteen months the patient died On TDOSt-mortem examination the posterior plate of the posterior \oaliof tlw cricoid cartilacje was found to be diseased, and there was I fistious communication at the base of the cartilage between the food and air passages. The history of this case points to the probable origi^ of the disease in the cricoid cartdage at a date antecedent to any laryngoscopic treatment; and I would call :Son to the ^fact ^at the pait operated on-the anterior commissure of the lai7nx-was wUli^i the larynx whilst the necrosed cartilage may ahnost be said to have been xoithout that organ, and nearly °an inch from the seat of the growth. 3 As regards the question of the conversion of benign into malig- nant growths, I may mention that in my fii'st series of growths there was one case i which at first was believed to be papillomatous, but .subsequently proved to be an epithelioma. In this case, the tuU detaHs of which will be found in my work, the patient's thi-oat was so irritable that only three laryngoscopic seances were attempted, and I only once succeeded in passing forceps into the larynx. As the whole growth was subsequently removed by thyrotomy, I cannot imagine that the single endo-laryngeal operation could have converted a benign into a malignant growth. The whole subject has recently been so ably discussed by another physician ^ that I cannot do better than make use of his observations. Whilst allowing that benign oTOwths sometimes assume a malignant character in the entire ab.sence of surgical interference, the writer calls attention in this TespecttoVirchow's^ opinions, who admits that persistent irritation of healthy tissues may lead to the formation of heteroplastic growths. The author justly maintains, moreover, that the degeneration of benign into malignant neoplasms never takes place except when there is an inclina- tion to constitutional vice ; and he points out that under these cii'cum- stances the change may take place, with or without surgical inter- ference. He further remarks that even frequently rexJeated local irritation does not produce degeneration. This has been most noticeable in those cases in which, in consequence of repeated recurrences, laryngoscopic treatment has had to be recommenced de novo many times, sometimes even on four, five, or six occasions, untU finally a complete cure was obtained. In some cases of growth, especially in recurrent papillomata, I have operated from time to time for many years without ever observing any malignant degeneration. Indeed, in the many hundred cases of papillomata that have been operated on, I only know of three iastances (Gibb, Mackenzie, and Rumbold) in which growths origin- ally benign afterwards assumed a malignant character. I am not aware that there is the slightest evidence that in any one case treatment exercised an unfavourable influence. Were, however, the conclusions on the above points of quite an opposite character, the symptoms are often so inconvenient and sometimes so dangerous, that in by far the greater number of cases ■that come under notice, it would stiU be necessary to adopt measures for the removal of the growth, or for the relief of the symptoms it causes. These measures may be either palliative or radical. 1 Op. cit. : Case 87, p. 183. 2 " London Medical Record," November 15, 1878, p. 4 —ends the insufflation of a i:&„gtin,«^^^ iney ^"^^ „,„,f^ee of the mucous membrane of the iaiynx. fh tiS'eLin^hat if siiffleiently powe^^^^^^^^^^^^ this reason I now verj- Bcldoin ^^^^^^ „ut, Ocdmnie CfmfenA— galvanic caiiieij j ,^ either .vithkinfe-ia» ,nstnjm^^^^^^ If£''; tStwir^S^cl foi the destrnetion of laryngeal growths T^pmovinn Groictlis.— In certain eSinot be removed through due to The ditaenlty of ta7"f ^^P'" ''""^^^^^^^^ to its inaeees- the large size or e^^^^' Cthe oeein.-ence of tf Op. oit. NON-MALIGNANT TUMOURS OK THE LARYNX. of the patient. In the case of very young children also, an extra-laryngeal method may be necessary. The kro-e size of a growth does not, m itselt, call for external treatment, some of the largest growths having been removed par vias naturales} The extreme density of a growth sometimes presents a great difficulty to laryngoscopic treatment, but with strong cutting forceps, this difficulty is only insuperable in the case of ecchondroses, and it is very questionable whether radical treatment should be attempted for their removal. The growth may be so situated that it cannot be completely eradicated from above. This occasion- ally happens in the case of growths springing from thoj anterior wall of the larynx below the vocal cords. In one of my cases of this sort, the evulsion was incomplete,^ but in two others the tumour was entirely eradicated. Wlien a growth, however, is situated in the ventricle, and only slightly projects from the ventricular orifice, it is sometimes impossible to remove it entirely from above. The projecting portion may be cut off, but the base remains. The occurrence of inflammation or spasm of the glottis, on attempted laryngoscopic treatment, may render the com- bined method necessary (tracheotomy having first been per- formed, and evulsion being subsequently effected througli the fauces), but it does not in itself justify an extra-laryngeal operation for evulsion. An insuperable irritability of the fauces, or an extremely nervous condition of the patient, may, however, render laryngoscopic treatment impossible ; and in these cases an extra-laryngeal treatment may be necessary. In the case of young children ^y\\o cannot be taught to submit to laryn- goscopic treatment, extra-laryngeal treatment may be re- quired ; but it must not be forgotten that A^ery young children have been successfully treated with the aid of the laryngeal mirror. Contrrx-Indications for extra-Lanjngeal Methods. — It may be stated as a cardinal law, that an extra-laryngeal method ought never to be adopted (even where laryngoscopic treatment cannot be pursued) unless there be danger to life from mffoca^ tion or dysphagia. Direct incision into any part of the air- passages is always attended with both immediate and remote danger to life, the amount of risk, however, not being great, as a rule. Dysphonia does not justify operations, which, • Mackenzie : Op. cit. : Appendices A and C, Cases 3, 52, 92, 95, &c. Ibid. : Appendices A and C, Case 24. 324 DISEASES OF THE THROAT AND NOSE. thougli easy to perform, may be ''.'J, ,tSaWe foilhl Heace an extra-laryngeal operation xs J^f ^^^^^^^ ^'^J^ -E^si^p'— ^^^^ ft«.<,« 0/ tot proposed for H'^''>^l--^}'l,'^F?^lj i.o,vths ty Desault, at the end "In cases of polypi of the larynx tne fold; viz., the extirpation, ^^g^^^^. l^^^^^i^C^^^^ neces- .e-establishment of a P-ag^ ^^^^^^^^^^^^^^ ^^^J^^^^, l,,y,geal sitate laryngotomy. It larel^ nappe , excrescences project so far ^^^^J^^.^^^^^^ naturales."^ seized and extirpated j S'tf ^ till the year this operation. . operation may be reqmred Indicatwns foi^^^^^^^ in the cavity of the larynx, for the removal dysphagia, and cannot be re- which canse great ^f^^^^J'JJ or for the e.ailsion moved ^^th.^^^ti \?rcdot ic^^^^^ of growths in the ^,^,ongh the crico-thyroid pated by ,^^^?f ^^^^^f tSA that this operation wonld xnembrane) {^/^^f ^f children ; but the facility with t^hifevefvJry ^ou^ c^iic-ii can be treated l.r„ .chirurgicales,' by mcnai. NOX-MALIGNANT TUMOURS OF THE LABYNX. 325 cally has already been pointed out; and it must not bo forgotten that when the larynx is small, thyrotomy is much more likely to lead to injury of the vocal cords. Dr. Paul Bruns has successfully refuted the assertion that either the very large size, extremely hard consistence, unusually broad insertion, unfavourable situation, or multiplicity of the neoplasms, is, a priori, sufficient to contra-indicate a trial of the endo-laryngeal method. " It is only m certain rare ex- ceptional cases," Paul Bruns observes, "in which several of these nnfavourahle conditions occur together, that we are entitled a in-'iori to consider the attempt at removal jjer vias naturales as having no favourable prospect, e.g., in some cases of soHd tumours with very broad bases situated below the glottis or originating in the ventricles." Here he shows, that out of 1,100 neoplasms, there were 602 papillomata, and 346 hbromata (constituting together 86 per cent, of all these growths) ; further, that 836 out of these growths originated from the vocal cords, while only f ths per cent, were situated below the glottis or in the ventricles. Consequently it is proved that three-fourths of all laryngeal growths are of such a nature and so situated, that they are well suited for endo-laryngeal interference. Whilst proving further by a good many examples, that growths springing from the under surface of the vocal cords, and those originating within the ventricles, have been and may easily be extirpated through the mouth if they are pedunculated, he, nevertheless, admits that subcordal or ventricular neoplasms, which have no pedicle, or are seated on a very broad base, or show an inclination to recurrence, belong to the department of laryngotomy. For the removal of subcordal growths, however, he recommends- partial laryngotomy (cricotomy or crico-tracheotomy with preservation of the thyroid cartilage), and only sanctions thyrotomy for the extirpation of tumours originating witlain the ventricles. Method of Procedure. — The first question which arises is whether tracheotomy should or should not be performed &s a preliminary measure of safety. I agree with Paul Bruns, " that previous or simultaneous tracheotomy, although it has been performed in by far the greater majority of the cases, is not required by the nature of the operation, unless there be other conditions necessitating its performance, such as dyspnoea." If tracheotomy is first performed, thyrotomy shoidd not be at once carried out, but endo-laryngeal treat- 326 DISEASES OP THE THROAT AND NOSE. xnent sWd l^e careMly attempted when th^^^^^^^^ lias been worn for a few weeks. Ibis failing, the surgeon caieluuy Qiviueu J ossification lias taken SS' be" Jtttri, ttlSn>W: divisiff the cartUag relations of tlie .'"""l f . '° ^ jhould not he allowed permanent jhoma T^^^^ ^ Te^f :idel7apa.t means of '^^^^^^ Xeannre SwTbS t^^nXoid n,e,n- bralto^rb; divided along ~ ^^If^rS rt^d'be divided, by a hon.«nt«„ ak.n^ he nppet into the openirrg and, gtnded by r^ and to nev^^ J^^ goscopie knowledge ot the «e^, to w"' . „j Srowt'h «th a hook or forceps a^ cW .tj^^ 1^^ short curved scMSors. 'J» »X „rowth may sometimes bo command of the °f •.*Vbeh " previously seized, or r:rrtstrs:u!s^^^^^^^^^^^^ . • • 4-1^ ^r,«^«tpd on by Krishiaber and I'lancnon 1 This precaution is justly msisted on oy ^ (- Faits oliniques de Laryngotomie. l-aiis, 15 ,v NON-MALIGNAXT TUMOURS OF THE LARYNX. 327 its removal,^ and the surgeon is obliged to desist from tlio operation. If all goes well, after tlie growtli lias been excised, its base should be firmly touched with sohd nitrate of silver. Actual cautery, acid nitrate of mercury, and galvanic cautery, have all been used, but I prefer the nitrate of silver, as less likely to give rise to laryngitis, and iiuite as effectual when applied to a raw surface. The two alaj of the thyroid cartilage should then be care- fully brought together, in their exact normal situation, with two silver sutures, and the edges of the wound united with plaster. The canula should be aUowed to remain m the trachea, for, at least, a few days, until aU danger has passed off; or if there be any lilcelihood of recurrence, till further steps have been taken to effect complete eradication. _ In some cases the cricoid cartilage has been divided, and though no harm appears to have resulted from its section, it is better, if possible, to leave it intact. Krisliaber'^ justly remarks that division of the cricoid cartilage is altogether unnecessary ; for whilst, on the one hand, it does not facilitate the removal of growths above the vocal cords, those below the glottis can easily be removed through an opening either in the crico-thyroid membrane or in the trachea. Comparative Merits of TMjrotomy.—TJnlil^e the opera- tion conducted ^^e?' vias naturales, the procedure now nnder consideration is a very serious one, both as regards the danger to life and the risk of destruction of function. In 1873 3 I published some articles on the results of thyrotomy, based on forty-eight cases, which comprised all then published. The following is a brief summary reduced to percentages, and placed in a tabular form : — Pel- cent, on 48 oases. Complete success * .. .. .. .• 14-58 Partial success . . . . . . . . • ■ 22-91 Death 8-33 Severe dyspnoea requiring use of canula . . 31-25 Severe dyspnoea requiring fresh operation . . 8-33 I have also tabulated the following other results, which " PaulBruns: Op. cit. p. 167. - Op. cit. 3 " Brit. Med. Joui-n." May, 1873. Complete success is understood by me to maan recovery of perfect voice and perfect respiration, and absence of recurrence of growth ; partial success to mean recovery of one function with injm-y to another, or temporary recovery of both functions, but subsequent recurrence of the growth. 328 D[SEASEa OF THE THROAT AND NOSB. live based on thirty-nine cases of henign growth, in wluclv the voice being atfected before the operation, the patient survived more than a few days : — . T_ • . . 40-0 per cent. Aphonia ^ Dysphonia . . . • • • • • ' ' n n " Modified voice .. ■■ ■• .■• r m " Not stated, but probably defective voice 6 G6 „ Recurrence, or incomplete removal .. m „ The following are some o^ the conclusions which I arrived '{^) That the operation ought never to be performed for loss of voice alone. , ^ ,i_ (b ) That the operation should be confined to those cases- in which there is danger to life from suffocation or dv^Dha-ia, and even then should only be performed after an experienced laryngoscopist has pronounced it impossible to remove the growth ;jer vias 7iaturcdes. Dr. raiU Jiruns in his valuable work on the relative merits of thyrotomy and endo-laryngeal operations for the removal of growths,, remarks • "I quite agree with Mackenzie that 'laryngotomy is only iustifiable Avhen an experienced laryngoscopist has declared the removal of the growth per vms naMrales- impossible^ ("Brit. Med. Jour.," May 3, 18^3, V- f^)- 'only, I shoidd say, after he (an experienced laryngologist) has attempted the removal in vain." . „ ^, , • In order to thoroughly weigh the merits of thyi-otomy, it is. necessary to consider the prospects of the operation : (1), n relation to the preservation of life ; (2), m relation to the •ecovery of voice and (3), in relation to the immunity from ieculrence. Each of these points will now be discussed m '^1f) In Relation to Life -In division of tlie laryngeal cart ies there is always some immediate dangei-. One patient dS from econdaryhLnorrhage a few ^ays after the 2^;- ?i^n, and several others have rapidly f^^^^^J^l nneumonia or metastatic abscess of the lungs. In Di. Outtei s caseThe m^^^^^ Avas almost suffocated during the operation ;. and n one of Navratil's earher cases, the haemorrhage was. a a mi^rand the patient nearly died from Hood which passed down the t-ch- ^^^^^^^^ ^1 :;-:ttS-:^tit;^^ 1 Op. cit. KON-MALIQNANT TUMOURS OF THE LAUYNX. 329' rouud the wound, and the patient was in a very critical state. . The nsual risks attending the ordinary operations tor- opening the air-passages, are also, of course, present, and tracheitis or bronchitis may supervene. In addition to the immediate danger, there is also the contingent risk of clu-onic perichondritis at a later period. (2.) In Relation io Voice.— In discussmg this question,. Bruns shows that the operation is very fatal to the vocal function. He takes exception to my statistics i on the ground that I have estimated the functional result together with that, of the operation, in a general way, without stating whether the whoie growth was removed, or whether recurrence took place or not— a method wliich natmvally yields untrustworthy results. Bruns, therefore, carefully excludes from his- statistics all those cases of final alteration or loss of voice in wliich tliis change could possibly be attributed to any other cause than the operation itself. Thus, out of the ninety-seven cases on record, thirty-eight only can be used for the decision of the question, whether the operation is, in itself, dangerous to the vocal function. Of the reality of this danger there can, however, be no doubt, for in 47 per- cent, only (eighteen cases) out of these thirty-eight cases, was a normal or nearly normal voice restored or retained, while in twenty cases, the voice was either completely lost (six cases), or reduced to nearly complete aphonia or extreme hoarseness (fourteen cases). We see, therefore, that in the majority of" cases, the operation itself brings the vocal function into great danger. (3.) In Relation to Recurrence of Growth. — It might be- expected that extirpation could be more completely effected when the thyroid cartilage is divided, and the larynx thorougldy exposed to view, and that thus recurrence would be less frequent ; but this supposition is not borne out by facts. Dr. Paul Binmshas well pointed out, tliat the question of recurrence mu.st be decided upon an examination of the cases of papilloma only : for iibromata do not recur, and the number of sarcomata operated on hitherto, is too small to permit of any satisfactory conclusion. Further, only those cases can he made use of which were under observation for a considerable time after the operation. Of Dr. Bruns' cases, one was only observed for five weeks, but most of them were kept in view for many months and even years. Distinctions of age must also be taken into account, children being separated for- comparison from adults. > " British Medical Journal," 1873, p. 488. 330 DISEASES OP THE THROAT AND NOSE. recurrences, but the latter niiiuuei ^i.jf.v, therefore do not .rowth not ^^een « X^^^^nl^^^^^^^^^^^^^ properly belong o the cate o^y^^^ ^ . „^t, however, that the cases oi . J^, r)erformed almost without than the others, the operation havmg been pert five of soUtary P^pil^oma th^^ ^-^^ 1 S-rai^lgS^o^^er^^^^^^^ the above- mentioned precautions, t^*^^-?,.'^^ "^Jy.'^^^edTor these statistics. currences. In thuty-one cases lue p i multiple and four cures and seven ;J^,ll'^ls^^ •difEuse (twenty-thi-ee cui-es and ten lecurrencesj . were only cui-ed after repeated operations frequency of re- These statistical tables show, ^l^erefore that the^ir^^^^^ assertions of the partisans of thyi-otomy. _ The following is an abstract of Paul Bnxns' conclusions on the more important matters : (A 1 ThWomy is not dangerous to life, nor fS";!" »» P»f ™; r^tf of res :^tSat.;"?aVf se.«i^, against reonxrenoo fnLTS^SiSl^S — ^^^^^ ondo-lar^goal operation. . i.-u^„f„Trnr should not be performed if it ^(C.) Even in tins case ^^f it°^.otomy (division of the caA possibly be avoided, but P^^*^f^^^3^\:5^»°f the cricoid cartilage .rico-thyroid "Smuch as everything depends c^SgrK the StSi^—siu-e of the vocal cords). 1 Op. oit. p. 1^7, et seq. NON-MALIGNANT TUMOURS OF THE LAKYNX. (D.) In iirgent cases, in wHch tracheotomy has to be performed for the reUef 6f dyspnoea, thyrotomy shoidd never be ixndertaken until removal by the endo-laryngeal method has been hrst attempted ; and in these oases success may often be obtained by "partial laryngotomy, the tracheal incision being prolonged through the cricoid cartUage. , . -n i. (E.) If after endo-laryngeal removal of papillomata recuiTence takes place, the same method ought to be tried over and over aga-in, as there ai-e many cases on record, showing that after frequently- repeated operations complete cm-e was finally obtamed. On the subject of thyrotomy Dr. FauveP remarks, I am extremely astonished to see surgeons, and stiU more so speciahsts in laryngoscopy, when they have only to deal with a sunple polypus not menacing the Ufe of the patient, stiU having recourse to this bar- barous method, which consists in making an opening m the neck tor extracting, by this dangerous, and often, too narrow way, tumours of a gi-eater or less volume and consistence. The laryngoscope shows the polyp as plainly as possible ; and also its seat, form, and size It is therefore useless, not to speak more strongly, to establish, at the cost of a severe andbloody operation, an artificial opening into the larynx. This opening has no other result, I repeat, than to expose the polyp and permit an operation — two conditions which are completely ful- filled by the laryngoscope." He fui-ther proceeds to point oiit the danger of the operation from hsemoiThage, and remarks that "in one case of thyrotomy, he was obliged to apply thirty-eight ligatures, though tracheotomy had been performed a month previously, and the patient wore the canula dui-ing the time the thyrotomy was being imdertaken." Removal of Growths hy Division of the Thyro-Hyoid Membrcme, or Supra-Thyroid Laryngotomy. — This metliod of treatment is indicated for the removal of large growths ijituated at the upper orifice of the larynx, -which cannot be taken away j^er vius naturales. The operation, originally proposed at about the same time by Malgaigne ^ and by Vidal de Cassis,^ was first carried otit in the year 1859. The operator was Dr. Prat, a surgeon in the French navy, stationed at that time at Papiete, the ■capital of Otaheite. The patient, wlio was the subject of itdvanced pidmonary phthisis, suffered also from such extreme difficulty of swaUoAving, that he could scarcely take any food. The dysphagia was due to a growth, which appears to have been situated on the under-surface of the epiglottis ; it coidd be, felt Avith the finger, but all attempts to seize and remove it through the mouth entirely failed. By operating after the manner recommended by Malgaigne, Dr. Prat easily removed the growth, which was of a compact fibrous structure and ^ Op. cit. pp. 227 and 229. - The claim to originality is made by Malgaigne in his " Manuel de Medeoine operatou-e." Paris, 1871, 7me edition, p. 625. ^ Velpeau : " Medecine operat." 332 DISEASES OF THE THROAT AND NOSE. Sreyish-wliite colour. No vessels were tied The wound healed quickly, and the symptoms fi^m which the pat en had suffered ^appeared. He died shortly -^^^^^^^^^ ^^'^l phthisis, and at the autopsy no trace of the growth was to be found 1 In the year 1863 FollmS performed a sundai ope-tion with complete success The neoplasms were- extirpated, and the patient was entirely cured • Transverse incision througli the thyro-hyoid memhrane .houM accordinc^ to Malgaigne, be made along the lower Wehfand parallel with,°the hyoid bone, through the iSr siiperficial fascia, the inner half of the sterno-hyoid S^sdes,\he thyro-hyoid membrane, and brane which extends between the base of the tongue and the epio-lottis, and forms the glosso-epiglottic ligament The side Jf the ei iglottis should then be seized and drawn through the wound. The growth can then be removed, according to h Xmstances^of the case, by ^oury, sc.ssoi^ or ^^^^^ ceps It may be stated that FoUm divided the thyio-hj oid membrane along the upper border of the thpoid cartilage ha"£ rather lower dofn than advised ^ff^l^^l^^ a view of avoiding the epiglottis ; and as far as I ?au gather from the report of Ms case, the incision was carried fur hei oZLls than in Prat's case. The latter 1-oeedj certa^y renders the epiglottis less likely to be wounded, but httie Tmuit is alforded to the valve by -king ^^e «n a fpw cent metres lower down than recommended by Malgaigne It must also be remembered that the more external the nc£^is carried, the greater ^^^^ ^'^-f\:lJ''^£ z-?irt::r?-ni^» - - - ^ ""-^^S^X^^or^ is unattench^dwitb any 1 Gazette des H6pitaux." 1859 No. 103 P- 809 2 ' ' Ai-chives Genferales de Medecme. H evner, iso / . NON-MALIGXANT TUMOURS OF THE LARYNX. 333 •out, always the danger of subsequent caries ; but it is well known that injury of the elastic cartilages, though it may cause temporary inconvenience, is unattended with permanent risk. Not only do we frequently find that patients, recovered from tertiai-y sypliilis, with the mere stump of an epiglottis, can swallow perfectly well ; but it has already been proved, in the celebrated case of Prince Mui-at,i that the epiglottis may be suddenly cut away witb only temporary inconvenience. Again, most hospital surgeons must have frequently met with extensive suicidal wounds of the thyro-hyoid membrane involving the epiglottis, which have healed rapidly without iiny bad results. This last fact has been illustrated by some remarkable cases by Kiinst.^ Removal of Growths ' by Infra-Tliyroid Laryngotomy {through the Crico-Thyroid Membrane), or hy Tracheotomy. — This mode of eradicating growths was recommended by Professor Czermak in the year 1863 ; but it was first success- fully employed two years later by Dr. Burow, senior,^ of Koenigsberg. In the year 1869 it was carried out, for the second time, by myself.** Since then eleven other cases have been placed on record, aU of which are briefly detailed in Paul Bruns' work. The operation is recommended for the removal of laryngeal growths situated in the sub-glottic region, as well as for tumours in the upper part of the trachea, when, in such cases, laryngoscopic treatment cannot be carried out. Paid Bruns strongly recommends this opera- tion for the extirpation of tumours originating from the iree borders and the lower surface of the vocal cords or from below the glottis. If they are small and peduncidated, the crico-thyroid membrane alone, or the cricoid cartilage in addition, may be divided, but only if previous endo-laryn- geal attempts at removal have been unsuccessful; if the growths are large, and attached by a broad base, laryngo- tracheotomy should be adopted, without any endo-laryngeal attempts, as by this operation alone a thorough cure can be expected. ^ In this historical case, which occurred at the battle of Aboiikir, half of the epiglottis was carried away by a musket-ball. Under Baron Larrey's treatment the patient recovered. Another similar case occurred in the same campaign, with an equally fortimate result. (Larrey: " CUniqiie chirurg." t. ii. p. 142; "Relation cliirui-g. de 1 Armee d'Orient," p. 286, quoted by Ryland.) • " ErbfE. der oberst. Luftwege." Leipzig, 1864, p. 45. "Deutsche KLLnilc," vol. xvii. p. 165. ^ Op. cit. : Case 81. 334 DISEASES OF THE THROAT AND NOSE. A few (lays bofore evulsion is attempted an incision should be made as in ordinary (erieo-thyvo.d laryngotomy S^e crico.thyr„id opening should bo --'"1//^^;*^^ out and all the membrane, muscle, and superhcial parts elvS so that nothing is left but the two car^=rla^^^^^^ made wiih one ot °j ^^^^.^^ „,ust S'Srand gC^- removed with short 'ti*f :^;ation can only^^; Performed wh«re the ^erico- tlivroid membrane is oi average size , li. >' ffect removal, tracheotomy shonld 1- Perfo^-f - growth. in ^^1^^^^'^° ^yith retractors, in Sde7ffSs=:tri^tf — ly passed into nl7;:Uent shonld coi.in.e to -^the ^i^^ S^lS^^e^iSof^— ta.ep^^^^^ [MALIGNANT TMOUES OF THE LAEYis^X. Under this head are included (1) Carcinomata, and (2) Sarcomata.] CANCEE OE THE LAEYNX. Latin iJg.-Carcinoma laryngis. . i^'renc/i i:ri.— Cancer dn larynx (?.r«.a« ig.-Kvebs des Kehlkopfs. Itcdian i;g.-Cancro deUa laruige. _ _ MALIGNANT TUMOURS OF THE LARYNX. 335 ears) sometimes to dysplicujia, and ultimatelij causing death either hj marasmus, or if tracheotomy has not heen i^erformed by ajmaia. JStioIuf/i/.—Tho. cause of cancer of tlie larynx, as of malig- nant disease in general, has not yet been discovered. _ With respect to age, lilce the same disease in other parts, it is more frequent in advanced periods of life. The foUowing table ot 53 cases occurring in my practice illustrates this point. It^ will be seen that nearly the whole of the mortality {i.e. 83 per cent.) takes place between the ages of forty and seventy. From 10 to 20 years of age . . ,, 20 to 30 ,, ,, 30 to 40 ,, ,, 40 to 50 ,, ,, 60 to 60 ,, ,, 60 to 70 ,, ,, 70 to 80 ,, Ziemssen^ publishes a table of 76 cases, collected from various authors, which gives very similar results, but includes- 3 cases under nine years of age and 3 between the ages of ten and nmeteen. As regards sex, 42 of my cases were men and 11 women,, whilst of Ziemssen's 76 collected cases 60 were males and 16 females. In 44 cases of laryngeal cancer observed by Fauvel,- ihe relative distribution with respect to age and sex is almost identical. Symptoms. — The subjective symptoms of cancer of the larynx are not of a very distinctive character. Pain, dyspnoea, and dysphagia are generally present, but these symptoms vary according to the stage and exact site of the disease. My experience accords with Taiivel,^ who states that at first the pain is confined to the larynx, and that not until ulcer- ation has commenced does it radiate to the ears, orbit, and forehead. Pain is sometimes felt in the submaxillary and cervical glands, but this is comparatively rare. Objectively, the groups of symptoms presented by laryn- geal cancer are striking, and almost always sufficiently characteristic to enable the observer to arrive at a definite * " Cyclopsedia of Medicine," vol. vii. p. 891. * " Traite pratique des Maladies du Larynx." Paris, 1876, p. 683. et seq. ^ Ibid. p. 707. Cases. 1 2 6 10 18 15 1 .•336 DISEASES OF THE THROAT AND NOSE. .minion as soon as the disease has hegun to ^1«^«1?P j;;); chancres Hoarseness, sometimes clue to miphcation o tlie cnanoBH. xxu , symptom, and sometimes recurrent nerve, is a veiy eaiiy »j > Drecedes aU other symptoms by months or even years Ihe d sturhLce of phonation is of course propessive, but as if rauvel has pointed out, the voice is seldom entirely lost, as it is !n larvncSal phthisis, and hy an effort the patient can in P-^r°.%T^^niie-biih ulceration takes place there is fetor of the bieath, and i self a stroig indication of the nature of he malady. Scera on advanced another symptom-heemorrhage, ^^'hlch wh^ serTous is almost pathognomonic of cancer-may be me vith There may be copious bleeding from one or more sma Ws being laid open, or the bloody discharge may only be rffiient to tinge the expectoration, which m almost all rases consists of ichorous muco-pus. «■ i The external condition of the neck seldom aMs any A .a n= TPcrnrds larvn^eal cancer. Occasionallj , how- :;e^at an^ a^^^^^^^^ st/ge%f the disease, the submaxUW Xds arTenlarged, and in some rare cases, owmg to mtra- faryngeS tumef^ction, the ahe of the thyroid cartilage are messed outwards, so that, as Isambert^ has pointed out the Sage feels ver'y much like a " crustacean carapace." More welY still, the cancer eats through the integument. As reC ds the general condition of the patient m laryngeal cancer the essential cachexia does not present itself so unXmlY as in malignant disease of other parts. This can A w Z Lnlained by the fact that the connection of the readJy J'^^^^J?^^^^^ ^tem is not nearly so free as nKiynf and o&^^ (see page 209). mere, how^ m tne pndiyii ,,vnlmio-ed as in those cases in Avhich LCeXed -ith, and tracheotomy has the ori<^inal disease having been m the larynx. rrZan/nr/o«comc appearances vary according to the stage The neoplasm appears as an undefined of the disease fi^^^ ^^i^^^^^^^^^^ .vhich clearly indicate its .swelling, with^^^^^^ nature. The site ot tne instances one of the vocal ^^y-^^^^''^ . . Aixnales d. Malad. de I'OreiUe et dn Larynx." T. ii. p. 8. MALIGNANT TUMOUES OP THE LARYNX. 337 first part to be attacked. Any part of the larynx may, how- €ver, suffer from the encroachment of the morbid growth, so Fig. 61. — Epithelioma of the Left Venteiculae Band. Fig. 62. — Epitheliomatous Ulceeation of the Right Aey- epiglottio Fold and Thickening of the Epiglottis. that after a time it becomes impossible to decide at Avhat point it commenced (Fig. 62). Sometimes the growth covers the entire larynx, as in certain cases of diffuse eiiithelioma ' • ^ e??ite reflex ixritatioB and - « ^^f^J'^^V.^ ...u-aeted rsL"t G— S ai-tiflcia, ™al apparatus (.e Tracheal Instruments) may be used. 1 Op. cit. p. 716. 2 "Lancet," October 13, ISJ. MALIGNANT TUMOURS OF THE LARYNX. 343 The operation, however, is not always of so simple a cha- racter as it has been described, for when the surgeon has made some incisions he may find that the disease is much more extensive than was previously supposed. Thus in one case Langenbeck Avas obliged to tie 40 arteries, to divide the lingual and hypoglossal nerves on both sides, and to cut away the two sub-maxillary glands and a large portion of the posterior half of the tongue. In a case of Billroth' s, it was foimd necessary to remove the larynx, the three upper rings of trachea, the thyroid gland, the lower part of pharynx, and a large portion of the oesophagus. Extirpation of the larynx is in fact an operation in which, as Dr. Paul Kocli^ points out, " the sldll of the surgeon is, in some cases, shown by the patient not dying under his knife," The following analysis of the annexed tables shows the result of all the operations which have been performed up to the present time : Of nineteen cases operated on, one patient died six weeks after the operation from pericarditis, resulting from the passage into the mediastinum of a bougie, used for dilating the oesophagus, which had undergone cicatricial con- traction as the result of the operation ; eight patients died from collapse or pneumonia witlim . a fortnight — in other words, directly after the operation, viz., 1 on the 2nd day, 1 on the 3rd day, and 1 on the 4th day ; 2 on the 5th day, 1 within "a few days," 1 on the 11th day^ and 1 within 14 days. In seven instances recuri'ence took place within a few months after the operation, viz., once in 3 months, once in 4 months, twice in 6 months, and once each in 7 months, 9 months, and 10 months respectively. Three cases were cured, one of which was an example of carcinoma and two of sarcoma ; in one of the latter cases the patient died 18 months after the operation from pulmonary and tracheal phthisis. In these three cases the disease was absolutely confined to the larynx, whilst in many of the others the neighboui-uig tissues were also involved. It has already been shoAvn that, owing to the arrangement of the lymphatic system in the larjaix, disease of that part does not quickly infect the constitution. This fact favours the prospects of extirpation of the larynx, when the neoplasm is confined to its cavity. In any case, the rescue of three patients out of 19 (15-7 per cent.) from certain death must be regarded as one of the greatest triumphs of modern •surgery. 1 " Annales de r Oreille," &c. March, 1879. 344 :!liaraoter and Situation of the Growth. Carcinoma of I the laiynx. Carcinoma of the larynx. Carcinoma of the larynx. Adeno-fibro- ma carcino- matosujn. Carcinoma of the laiyux. iient's ( Sex Male. ( Male. Male. ■ Male. > Male. ^ ■ o CD >o 5 Date of Opera- ; tion. « 1873, i 31st Dec. 1874, 28th Apr. CO o o S 3 ? a I-- 1^ S |(g ^ . 00 »o ■ rH O O JO . - 345 s p S - ^ rS -^^ I — . O S S J ft o : O bo 3 ^ -3 a N " ^ _, O -w N Sec f f-< 'S ^ a o " — ^ 83 03 o o CD 5^ S g f^. p -W O O 2 o ^3 Pi -girl W -f^ ft o -c^ o ^ ftbo'^ .a si ^ o pj S E>5 o ce o u o o ft-ts -IJ . 03 03 O o a o .a ^ S ftfl £;> O 03 -e kSPtj-s M prt r> . d " 03 .a o 03 3.2 . rSfS 03 2= PR 03 CS 3 a |J3 03 pq 346 •2 ■5 •3 3 41 'A H PR O o M 8 § § .y -►^ '43 Q * "S 2 S Pi o . 03 c3 . . !-< S IJ (U o „2 2^|^'^^ 41 ° g^-s a a Pi.-' S.2 § S ■-3 ^ 1- *^l_J>. 00 CO VJ f^P^ ^ r-< 1 ^ ^ g- "3 o .5 aediate Eesiil )very. Death on the day from collt ,th on the ay after o] on from li ;atic pnenm 1 O CO Part Eemoved. ■ Larynx in toto, . -witli exception of tlie epiglottis and of a small piece of the cricoid cartil- age. Larynx in toto. i 1 ___! 1 i ■ Larynx in toto, L with exception of the epi- glottis. Character and Situation of the Growth. Epithelioma : of the la- rynx. Carcinoma. • a ^ . o « .3 O M O ^ O ___o_____ iient's C Male. Male. ) Male. d s3v o lO — 1 S Date of Opera- tion. 1876, IVTnv °g 0) a 1 'bo S 2 ) Gerdes (Jcvei - — 1 Beyhcr (Dorpi •OH 1 ^ 00 a> '96 IS 03 S 3 5 6 > O o u ^ pi ^ - o M o ?^ ^ > o3 O .ft o m B4i is. > ci o ■ ^ O c« 03 2 0^ 3 W H O O M H o 1 a t. o o Us t3 o C3 •H S o o o o o o o QD I— I K o a g 2 OD Eh a So ^ - :^ ^^ 9, o o a O O -J C3 O P4 i- f-l SECOND ABY CANCER. 349 Eeviowing the whole subject of treatment, our aim TOUst be to prolong life when possible, and in every case to promote the euthanasia when the inevitable end draAvs near. From the foregoing remarks it will appear that the first indica- tion can best be fulfilled' by resorting to tracheotomy before the constitution has suffered from the impediment to free respiration. When deglutition is much interfered with, the patient must be fed by means of the oesophageal-tube, or by nutritive enemata. In. order to relieve pain insufflation of morpliia (gr. to ^ mixed with powdered starch) may be employed once or twice daily with great advantage. By such topical applications alone it is often possible to keep the sufferer almost free from pain ; whilst at the same time swallowing is rendered easy, and the appetite frequently improves. Whatever means we may adopt for the treat- ment of the local disease, it must not be forgotten to supple- ment them by general tonic and analeptic measures ; and hy Avell-considered dietetic and hygienic treatment an attempt should be made to preserve the integrity of the constitution ■as long as possible. Secondary Cancer. This affection scarcely deserves the name here used, my •experience being similar to that of Dr. Fauvel, who remarks that ho has never met with a case of secondary cancer of the larynx originating in infection. ^ It is very common, how- ever, to find cancer involving simultaneously the posterior wall and sides of the oesophagus or lower portions of the pharynx, and at the same time the mucous membrane cover- ing the posterior surface of the cricoid cartilage. Occasion- ally, also, cancer commencing in the sides of the pharynx or root of the tongue extends to the epiglottis or ary-epiglottic folds. _ These are, in fact, illustrations of the contiguous •extension of the disease, and have been sufficiently considered xmdev Cancer of the Pharynx (page 81, et seq.) ' Op. fit. p. 748. 350 DISEASES OP THE THROAT AND NOSE. Sarcomata. Sarcomata constitute a variety of growth, wliich is com- paratively infrequent in the larynx, only five cases i having come under my notice. These giwths may ongmate ftom any part of the mucous memhrane of the W^' " one instance I met with a tumour of this kind (Eig. 66) A B Vm 66 -Sabcoma geowing feom the Posteeioe Sueface of the Ceicoid Caetilage. A The gi-o-wtli in situ. B The growth after removal. situated on the posterior surface of the cricoid cartilage. Two of my cases occurred in men aged respectively sixty-four ana forty-two ; the others in women, aged respectively hfty-thi-ee orty-thi-ee, and thirty-seven. In one of hese dysp^on- had existed for twenty-tln-ee years. As a rule sarcomata rapidly attat a considerable size,"^ so much so, that - a relatively large proportion of the cases either thyrotomy or extiipation of he laivnx has been found necessary. In one of my cases the surface of the growth was quite smooth, but m the others lTlZ l^^m.ted. The cdour is generaUy red, but in one nsIancTit was partly yellowish,3 and in another case it was krker than thlt of the neighbouring mucous membrane Durin. hfe these tumoiirs often cannot be distinguished by iheh appearance from papiUomata, and even after death, if J- A ■Wna '^<^ 40 and 95. and "Trans. Path. So^'^vor^xxi^TlTe^^^ ^ ^^^^ I lately saw mthDx^Stron^^^^^^ No. 92, 1868; also ^'^l^:^'''^^^^^^^ ^r^' '"''-^ andSchroetter: « S^^gol. Mitthen." Wien 1875 p. . 3 Laroyenne : " Gazette Hebdom. 18 / 3, p. ^ 80. SARCOMATA, 351 extensive ulceration has taken place, the naked-eye appearances cannot bo relied on. The true character of the disease can- not in fact be determined Avith certainty except by the micro- scopical examination of a portion of the neoplasm. These growths generally partake of the spindle-ceUed or fascicular character, but I recently met with an example of round-celled sarcoma, and the following is the microscopical report by Dil Stephen Mackenzie : — " Sections show the whole of the tissues infiltrated with small round cells, completely fiUed by a nucleus, and vnth. very scanty and delicate reticulum. The cells are most numerous in the sub -mucosa, where they pass in dense masses between the bundles of striated muscular fibres, and siuTOund the blood- vessels and nerves. They do not much encroach on the- mucosa. The epithelium covering the surface is in some places intact, but thickened ; in other places it is irregular, as though eroded and undergoing proliferation. Nowhere are there epithelial protrusions into the mucosa. Some reticiUated cartilage is cut. across in the sections, and the cartilage cells have fallen out ; the nuclei of the fibres are rmusually distinct." The prospects of the patient are much less satisfactory than in the case of benign growths, but more favourable than when cancer is present. In one case I succeeded in permanently removing the growth ^Jer vias naturales} and lSravratiI,2 Gottstein,^ Tiirck,* and others have effected cui-es in this way. On the other hand, Balassa^ attained success by thyrotomy, and Bottini " and Toulis 7 both restored their patients to health by extirpating the larynx. If the growth cannot be entirely removed by intra- laryngeal treatment, either thyrotomy or extirpation of the laryiix must be selected according to the site and extent of the RTowth. ' Mackenzie : Op. cit. Case 95. ^ "Berlin. Klin. Wochenschrift," 1868, No. 49, p. 501. ■ "Wiener Medizin. Wochenschrift," Dec. 30, 1868, No. 105 * Op. cit. pp. 576, 577. s Loc. cit. 7 Loc. cit. 35-2 DISEASES OF THE THBOAT AND NOSE. SYPHILIS OF THE LAKYNX. Latin ^^g.— Syphilis laryngis. French iJg.— Syphilis du larynx. German jSJg.— Syphilis des Kehlkopfs. Italian iJ^.— Sifilitide della larmge. Dfptnition —The local manifestations in the larynx of eonsfZional ' sypldlis, constituting the so-called secondary, Z Z lr hereditary phenomena, and grving rise to dys- phoniaor aphonia and sometimes to dyspnma. T'j^aloav —The precise causes which predispose the larynx to an attack of syphilis are not clear; hut in many cases the disease is prohahly attracted to the part through local weak- nesreitiaei hereditary or acqtdred. The season of the year Sas a marked iiofluence in causing the outbreak to take place n the laryngeal mucous membrane in the early stages and Z a ess extent later on. Thus out of 118 cases of secondary svDMis of which I have notes, 79 commenced between S?Dta xber 1st and March 31st, and only 37 between Aprd 1st S Augl 31st, whilst out of 110 cases of tertiary syphilis 66 commenced in the six winter months, and 44 in the '"^"tiSspeS'to the frequency with which syphilis affects +1 InvvJ,? as comiDared with other parts, the statistics of Wm^^l^^ of 218 cases if syphiHs in the dead Wdligk sliow ^ ^^^^^^^ ^^^^ ^^^^^^ ^ Tjf pel c nt the pharynx was affected, whilst the nose 10 1 pel cem. i observations give a some- 'fT^ZLtZlt Out of 521 cases Engelsted^ W what difleient rebuiu. syphilitic rnVsof ref:. >a,,ngeal syji"^- -^"XlV"' m which the phaiynx was aSectal (bee iaMe A.) Berlin, 1S69. SYPHILIS OF THE LARYNX. 353 With respect to age, most cases of laryngeal syphilis occur hetween twenty and forty, as will be seen on reference to Table B. Again, as regards the kind of syj)liLlis most frequently met with in the larynx, Table A shows that tertiary phenomena are more common than secondary, being in the proportion of eighteen to eleven. From tliis it would appear- that the larynx is most liable to be affected in l^atients in whom the constitutional malady has been of long standing. My colleague, Dr. Whistler,^ has, however, had a different experience, for out of 170 cases of laryngeal syphilis, 88 corresponded to the secondary, and 82 to the tertiary stage. TABLE A. Showing number of cases of syphilis in 10,000 cases of throat-disease seen at the Hospital for Diseases of the Throat. 2 , Primary— Males . Females. Secondary — Males . . .... 34S Females 143 Pharynx Tertiaiy- 491 Males 170 Females '. . .' . 163 ggg Heireditary— Males . . , , . . 2 Females i 3 / Secondaiy — Males . . . . , . 84 Females 34 Larynx * Tertiary — Males 120 Females Hereditary — Males Females , . 118 69 189 I 0 — 1 Tertiary- Males . Females . Trachea 2 1 — 3- 834 308 1145 \ " Med. Times and Gazette." Sept. 28, 1878 c ^■^^'^^ altogether met with seven cases of primary clS^' pharynx, only one was seen among the 10,000 tabulated A A DISEASES OP THE THROAT AND KOSB. TABLE B. Showing AGES of patients affected witli labyngeal syphilis. Males. fieoondary. ^^^^ ^5 Tertiary. 0 I :; :: ;; :: ui;io :: :. .. .. « 41 .... 20 to 30 22 ■". . .. 30 to 40 5* ' ... 40 to 50 I . . 50 to 60 . . 1 ■ • ■ ■ .. 60 to 70 ^ Q ■ ■ ' ■ . . . 70 to 80 '■ 84 Fejiales. 120 Tertiary. 0 Seoondary. _ ^ ^^^^^ 15 . . 10 !'. .. 15 to 20 ^ 11 \ .. .. .. 20 to 30 17 4 .... 30 to 40 2 '.*. *.". .. •• 40 to 50 29 15 , .. 50 to 60 \ y ■' '." .. 60 to 70 ^ 69 34 TABLE C. Showing the paiticolar conditions observed in syphilia of larynx. Second AEY. Congestion. Condylomata. TJlceration. Totels. Males .... 35 ^ 34 Females.. ..16 _ ~" 77 23 118 ■ 51 1 44 ■^•^ Teetiaey. Superficial yicera- l^eep andEx- Qummata. Totals. 22 Males .. 27 g ^ 69 Temales ..21 48 189» 107 27 5 > X. of tKese'c'ases there^at the same time congestion of «.e trac.ea and ^'rKThte'°ea^es'tKaB at the eame time secondary dxsease of the n-iTongst these 189 case, there were T of acute «dema. and 32 of chronic oedema . SYPHILIS OF THE LARYNX. 355 Si/mptoms.—The phenomena of laryngeal syphilis vary, in different cases and in different stages, from the mddest to the most severe. Thus the patient may suffer merely from a . slight inchnation to clear the thi-oat, or there may be extreme dyspnoea, advancing ultimately to such urgent suffocative attacks, as to require tracheotomy. Cough is occasionally present in the early manifestations, but rare hi the later stages. The vocal fimction is generally impaired, and whilst at the commencement of the attack there is often only slight hoarse- ness, this may ultimately pass into complete aphonia. There may be no odynphagia at first, but at a later period swallowing, in some cases, becomes almost impossible. The absence of pain, when the patient is not swallowing, is very characteristic. The pathological effects of syphilis in the larynx are ex- tremely manifold, and comprise every kind of lesion that can be produced in the part, from a mere erythematous blush of the mucous membrane to great thickening, destructive ulcera- tion, perichondritis, and necrosis of the laryngeal cartUages. In secondary syjphilis, condylomata are the most character- istic condition, but chronic hyperasmia (without mucous tubercles) and superficial idcerations are often met with. As will be seen by reference to Table C, I met with 44 cases of condyloma among 118 patients suffering from the early symptoms of laryngeal syphilis ; whilst among 88 patients in the same stage Dr. "Wlustler ^ saw 24 cases. On the other hand, Dr. Terras ^ only found a single example in a hundred patients, Isambert^ does not consider that there is such a phenomenon as laryngeal condyloma, and both Waldenburg and Le-vvin^ hesitate as to whether the characteristic mucous tubercles of syphilis are ever found ia the larynx, being inclined to relegate the neoplasms usually described as such to the class of gummata. Again, whilst Gerhardt and Eoth^ found condylomata in 18 instances out of 56 patients suffering from constitutional syphiKs, in a 'series of examinations at the Lock Hospital, I observed condylomata only twice among 52 patients. These Avide discrepancies may perhaps be accounted for in a measure 1 Ibid. " Thfese de Paris," 1872. ^ " Aimalesdes Maladies de I'oreiUe," &c. T. ii. p. 239. '' Eespiratorische Therapie," II. Aufl. 1872, p. 366. ' Loc. cit. p. 113. ■« Vii-chow's "Ai-chiv." Bd. xxxi. 1861, Hft, 1, § 7. 356 DIBEASES OF THE THROAT AND NOSE. by the different periods of the year at which the observa- tions were undertaken, some having been made m the Slimmer and some in the winter, but they are in part to be explained by the fleeting character of laryngeal condylomata and by the different appearance which condylomata present in th^ larynx as compared with the pharynx- a difierence which renders them likely to be overlooked. In the larynx they generaUy appear as smooth yeUow projections, some- times round, but more often oval, varying in diameter from three to seven millimetres, but in rare cases attaining a breadth of a centimetre. They are seldom so Avhite as m the pharynx, and the surrounding mucous membrane is not ceneraUy so congested. Moreover, they are less disposed to superficial ulceration, and they generaUy disappear quickly- even without treatment. The epiglottis and the mter-aryte- noid commissure are the parts which I have most frequently Fig. 67.— Condyloma on the Uppee STntFACE of the Epiglottis. found affected, but I have occasionally seen condylomata on the vocal cords. , i j,. Superficial ulcerations of limited extent are as akeady remarked, occasionally met with. They generaUy occur from six to twelve months after the primary infection, and heal after a few weeks' treatment. In secondary syphiHs, we also sometimes meet with very obstinate congestion of the laryngeal mucous membrane but it is often impossible to teU whether this condition is really due to the syphilitic dyscrasia. I found marked congestion in 51 out of 118 cases of secondary syphihs. In every one o these 51 cases there were at the same thne other yeU-marked symptoms of constitutional syphilis-m 2\cond^loma a ^ the pharvnx As I pointed out long ago^ there is nothing char^cteistS about L congestion of sypMis, I -^^^^ consider a congestion syphilitic unless ^^/^^ ^ marked evidences of the disease. Even then the laij-ngeal hyperemia is often the result of accidental catarrh, and m no 1 RusseU Eeynolds' " System of Medicine," vol. iii. p- 465. SYPHILIS OF THE LAEYNX. 357 sense due to the sypMlis. On the other hand, M. Dance lias "One so far as to describe roseolar, papular, and tuber cular eruptions of the laryngeal mucous membrane corre- sponding to similar manifestations on the skm. 1 have never been able to verify these observations, nor have they been conlirmed by other physicians. In tertiary syphilis the phenomena met with are ulceration, gummata, and cicatricial stenosis. The earliest, but not most frequent, symptom is obstinate superjidal ulceration, accom- panied by considerable hypersemia of the mucous membrane. Dr. Whistler 2 has well described this condition, under the name of "relapsing ulcerative laryngitis." When these superficial ulcers occur within a year of the primary affection, I have been in the habit of classifying them under the head Fig. 68. — Thickening and Ulceeation of the Epiglottis. of secondary syphilis, though this is a mere arbitrary distinc- tion. But when they appear thi'ee or four years after inocula- tion, they may fairly be regarded as tertiary. I have met with one instance of this affection in a patient who had been successfully treated fifteen years previously at Aix-la-Chapelle. The ulceration generally attacks the vocal cords, but I have frequently seen the inter-arytenoid fold, and occasionally the ventricular bands affected. Deep and destructive ulceration is, however, the charac- teristic morbid condition of the later stages of laryngeal syphilis. The ulcers may form three or four years after in- oculation, but they sometimes occur twenty, thirty, forty, and even fifty years after the date of infection without the occurrence of intermediate symptoms, and when, indeed, the primary cause may have even been altogether forgotten. Their effect is to produce great loss of substance, and the con- ' " Th&se de Paris," 1868. * "Med. Times and Gazette," 1878. Nos. 1480, 1484. 358 DISEASES OF THE THROAT AND NOSE. sequent changes in the form of the epiglottis and other .parts of the larynx are very remarkable. The ulcers may form m any region of the larynx, but the epiglottis is the part most frequently affected-one of the most common conditions con- sisting of general thickening of the valve, with ulceration of the central portion or lateral free edge (Fig. 68.) The upper surface is more often attacked than the under surface. Under these circumstances great dysphagia is usually expe- rienced, but when the ulcers are healed, swallowing can Pxa. 69.-DESTBircTiVE Ulceeation or the Epiglottis: ^^eg^ab Hypebteopht of the Left Ventbiculae Band ai.d Aet Epiglottic Fold. o-eneraUy be effected without trouble, even though nearly Cwhol of the valve is destroyed. When ^f^JJ"^^ pharynx are also ulcerated, there is danger of the edges ot Le 'epiglottis unitmg with them. /^^ a rise to one of the most dangerous forms of dysphagia as weU as to serious dyspnc^a. The ulcerative process frequently ■Fig 70 -Thickening and Destbhctive Ulceeation op Epiglottis. n . +i,o ■miVf.nn^ and sub-mucous tissues to a verj^ con- destroys the mucou and s ^^^^^^^^ ^^^^^^^ . siderable ^^^ent and s^^ associated with oedema, '^T^'lZ not^S^en^ followed by the formation of and IS also not ^^^g^ apt to occur on the inter- false -^^^^ffJ^'^y^flZ^^^^^^^^ the posterior wall 7m', rugate— y seen on the Ul cords. SYPHILIS OF THE LARYNX. 359 In these advanced stages syphilitic giunmata are occasion- ally thouo'h very rarely, formed in the suh-mucous tissue and muscles of the larynx. They usually appear as romid, smooth elevations (Fig. 71), generaUy of the same colour as tlie rest Fig. 71. — Gumma. of the mucous memhrane, but sometimes of a yellow tint. They are most frequently found on the anterior surface of the posterior wall of the larynx, and generally in groups (Fig. 72). Mandli mentions the case of a negro suffering Fig. 72.— Gtjmmata. from severe pharyngeal syphilis, in whom numerous gummata, of a greyish-yellow colour, could he seen on the epiglottis and ventricular bands ; and Norton" has described and figured a remarkable case, in which suffocation resulted from a gumma, the size of a pigeon's egg, in the right ary-epiglottic fold. The ulceration which results from gummata is of the 7' ,^97 173 113 lUl THckening .. l7o -^^^^ 97 92 Ulceration .. Hi ,czr 1 " Prager Viertel jahrsclirift, ii. 185G. LARYNGEAL PHTHISIS. 377 TMckeniiiff, either general or circumscribed was present in every case ; thickening with ulceration m 193 cases In „xy 100 cases examined after death, however, I foimd ulcera- tion in 97 cases, as will be seen from the annexed table :— Table F. rost-mortem [naked eye) appearances of mucous membram in 100 cases. Aryten.Cart. yocal Vent. „^tmoid Epiglottis. - Cords. Band. THcW ..81 ^ 81 90 93 SerTwa^ also necrosis, with separation of perichondrium by pus, in 15 cases ; perichondritis (thickening of perichondnum) m H cases without apparent separation of perichondnum; and ossification ot cartilages in 79 cases. Tubercidar infiltration, according to Heinze, is present in about half the cases of laryngeal phthisis, but it has appeared to me to occur much more frequently. The deposit can often be recognized macroscopicaUy as a smooth, elastic, yielding swelling of greyish-white or greyish-yeUow colour, which on its surface frequently shows a whitish- yellow deposit, either collected in little masses or confluent. Microscopically the appearance is very characteristic. There is general thickening of the diameter of the mucous mem- brane (equally affecting both the mucosa and sub-mucosa), .so that it becomes from three to four times its ordinary thickness. This is most conspicuous in the covering of the arytenoid cartilages, in the ary-epiglottic folds, and in the epiglottis. As regards the epitheUum, until ulceration has actually taken place there is no great change, even when there is considerable deposit of tubercle beneath the epithelial structures — a circumstance which is opposed to the view that tubercular mfiltration is due to the corrosive action of the sputa. The deposit consists of tubercles, wluch are made up of more or less circumscribed collections of cells of various shapes and sizes, having a somewhat concentric arrangement upon a scaffold of lymphoid reticulum. The tubercles, some very small, and some as large as a millet seed, have frequently, in their centre, a " giant cell," around which are lymphoid cells, and some few larger cells with nuclei of high refracting power. The tubercular deposit is found both in the mucosa and in the sub-mucosa, but always above the layer con- taining the mucous glands. It is sometimes deposited uniformly through the thickness of the mucous membrane, but 378 DISEASES OF THE THROAT AND NOSE. is much more commonly found in the most superficial layer of the mucosa, immediately beneath the epithelium. In the deeper layers of the nmcosa both the tubercles and the round cells are less abundant. Occasionally we meet with deposits of tubercle near the epithelium, wliilst the tissue between the deposit and the epithelium contains a few round cells and many capillary vessels, but no tubercle — a circum- stance which further tends to show that the tubercular ulcer origmates through perforation from witidn, not from without. The tubercle is of diSerent date : sometimes it shows fatty degeneration at its centre, sometimes such com- .plete caseation that only its walls remain. In describing the microscopical appearances I have made large use of the valuable work of Heinze already referred to. Until the pubhcation of his essay I had not given my attention to the minute liistology of this important disease, but since then my brother, Dr. Stephen Mackenzie, has made careful microscopical examinations of my^ recent pathological specimens, and has furnished me with the following report, which it wUl be seen fuUy confinns Heinze's observations : — " In the specimens submitted to me, the epithelium pre- sents no important alterations. The mucosa and sub-mucosa are gTeatly swollen and oedematous, and infiltrated thi-oughout with lymphoid cells, which occur both as a general infiltra- tion and in more or less circumscribed collections^ with a somewhat concentric arrangement. These collections are supported by a dehcate reticidum, and their centres are often pale and necrotic. The circumscribed collections of lymphoid ceUs frequently enclose two, three, or more large plates or spheres of protoplasm containing a great number of vesicular nuclei and delicate peripheral filamentous pro- cesses (giant ceUs). The appearances are, indeed, simUar to that which is seen in tubercular diseases wherever occurring. In the laryngeal mucous membrane there appears to be a oeneral infiltration (such as is commonly observed in chronic inflammation), associated with more or less well-defined and often coalescing tubercles. As regards the position of the latter, they occasionaUy appear to be placed laterally to arteries, but tHs may be only accidental, the irregular course of the vessels in the laryngeal mucous membrane not being favourable to tracing any relationship. Sometimes 1 "Ueber pathol. Veranderungen d. Kehliopfmuskulatur bei Phthisikem." Vircbow's "Archiv," 71-73, 1877. LARYNGEAL PHTHISIS. 379 they are close to the dUated ducts of the mucous glands, X\.h show some alterations. In parts both acun and ducts dilated, and whHst containing smaU ^0^^^ ?^^^^^ are surrounded by a considerable amount of ceUulai inhltia- Sn The tubercles occur at all depths from close beneati^ the epitheUum to near the cartilages None are free on the surface, except where it is ulcerated. ■u FiQ. 81. — Section theough the Right Akt- epiglottic Fold, SHOWING TUBEECLES IN SUB-MUCOSA. a Tubercles. 6 Mucous Glands. The cartilacjinous framework of the larynx shows the effects of tuberculosis in various ways. Perichondritis is characterized by the abundance of pus cells between the bands of the perichondrium. The suppuration is sometimes so active that the whole structure may disappear, and the cartilage lie loose 380 DISEASES OP THE THROAT AND NOSE. in an abscess. The intercellular substance of the hyaline cartilages first becomes opaque, and afterwards shows signs of fatty degeneration, wliilst the elastic fibres of the epiglottis become infiltrated with pus, and the cartilage cells disappear by fatty degeneration. According to Heinze, perichondritis only occurs when the tubercular process approaches the car- tilages or reaches the perichondrium, neither perichondritis nor chondritis being ever met with in cases of catarrhal ulceration of the larynx. I feel convinced, however, that this view is incorrect, and that perichondritis occasionally Fig. 82. Poetion of one op Tubebcles in peeceding Fig. moee HIGHLY MAGNrPIBD TO SHOW GlANT CeLLS. supervenes in cases of long-standing but simple chronic laryngitis. Heinze maintains that the largest swellings met with in laryngeal phthisis are not due to perichondritis but to tuberculosis of the mucous membrane, and that in eases of perichondritis the tumefaction is often very slight. Ulceration is the common sequel of the deposit of tubercle in the mucous membrane of the larynx, rriedreich has stated that the larynx is most frequently affected on the same side as the lungs, but I have not found this to be the case. On this subject Heinze remarks that during life it is impossible to be certam that the apparently sound lung is intact ; and further, that on post-mortem examination it is rare to find the rdceration entirely confined to one side. In fifty cases of pulmonary phthisis, he observed tubercular ulceration of the larynx in forty cases, non-tubercular ulceration of the larynx (but tubercular ulceration of the LABTNGEAL PHTHISIS. 381 trachea) in seven, and three in wliich there was no tubercu- losis Tubercular ulceration is characterized by the presence of tiibercles in the edges or bases of the ulcers, but ulcers must also be regarded as tubercular, even though no characteristic tubercle is present, when giant cells are found (either alone or associated Avith roimd cells) diffusely infiltrated in a reticu- lar structure. A few words are required as regards the special tissues of the larynx. Sometmies the tubercular process com- mences in the glandulce, the deposit of round cells, in the interstices between the acini gradually encroacliing on the membrana propria, and leading to the destruction of the acinous structure, so that a capsule which in a_ state of health would contain twenty or thirty acini is found holding only four or five of these bodies. At last the cap- sule is destroyed, and there only remaia isolated portions of degenerate gland structure. The ducts of the glands have the greatest power of resistance, and are often found in the tubercular infiltration intact with perfect cylindrical epi- thelium. Tubercular ulcers commencing in the glands have been carefully described by Eindfleisch,^ who observes that they begin at the mouths of the mucous glands, and in appearance are circular, and flat or fmmel shaped, with narrow but extremely yeUow borders. On section of the mieries, a mass of round cells is often found partly outside the adventitia, but for the most part amidst its fibres. Sometimes there is an abundance of tubercles, some recent and some of old date showing signs of caseation. In these cases the adventitia is generally destroyed, whilst the muscularis and inthna of the arteries almost always remain intact. The muscularis of the veins is, however, much more easily destroyed, and the lumen of the vessels undergoes great modification and contrac- tions. The capillaries show the same power of resistance as the arteries, their endothelial cells generally remaining unchanged, and their walls of normal strength. The capil- laries are often found in excess between the tubercular deposit and the lower layer of the superjacent epithelial cells. Tubercle is very seldom detected witliin the muscular structure, but Friinkel^ found the contractile substance the perimysium internum and corpuscles in a state of fatty degeneration. He states that the muscle-corpuscles were increased either in number or size ia aU the muscles he exa- 1 " Lehrl). d. Path. Gewebelehre " iv. Aufl. 1875, p. 325. 382 DISEASES OF THE THROAT AND NOSE. inined. Heinze rarely met with changes in the muscular structure, hut in two cases tubercles were present. Once a smaU fresh tubercle was found between the fasciculi, and once the deposit was in such abundance that only the section of two or three separated fibres remamed m tiie midst of the tubercle. In a few cases Hemze found the muscle-corpuscles increased in number It may be stated that these' changes in the structure of the muscles are the results of chronic nutritive deviations, and not specially characteristic of the tubercular process. -Where the characteristic semi-sohd pyriform swellings of' the ary-epiglottic folds are present it is almost S^no^sible to mistake the disease ; but where the thickenmg S not of such a defmed character the diagnosis is not qmte rlear The examination of the lungs will sometimes confirm a doubtful diagnosis, and where auscultation yields negative results, a careM search should be made m the sputa for the plastic tissue of the lung. The conditions which are most likely to give rise to an error are chi-onic laryngitis, ctaic oedema and syi^hihtic thickening or ulceration. In chronic laryngitis the sweUing is 'eneraUy much less than in laryngeal phthisis, whilst there is more hypera^mia ; in oedema the much gi-eater trans- Srency of the ^Selling differentiates it from phthisis, though rZIt be admitted^ in advanced laryngeal phthisis fPdema is usually added to the tubercular infiltration the tHckening is -ry irregular and the ulcers ,re o-eneraUy large and sohtary, and hence frequentiy um- Hterfl &ey are^also commonly surrounded by an inflamed ieola ' In phtliisis, on the other hand, the sweUmg is more .T.rl uniform whilst the ulcers are smaU, nimierous, smooth and The two diseases T-r'i'olftoltlrte h^y attack. Thus, when syphilis Sste e^ltt,'" is the' Ungual surface and free edge assails tiiejipioj » _ ^ tubercular ulceration, 7^'\ Te free ed" e of the epiglottis is often attacked it If inder smface and base which are more generally IS the ^^^^f ;XXted In both diseases the whole valve and more deeply aiiectea rn ^^^^ ^^^^^^ may ^l^^-^r^^^'Xt^ mceration over the arytenoid m syphilis than P™';'; ^lis, but very common cartilages IS «.«^P^f ^^^t^;^^^^ is ap/hcable to in tuberculosis, and the ^^^^^ J commissm-e of the vocal t^r"^:^^^^^^ "^'' LAEYNQEAL PHTHISIS. 383 but wliile phthisis generally affects both vocal cords, iu syphilis one cord alone is not luiconimonly ulcerated. The ulcerations in laryngeal phthisis may be extensive, but the actual loss of substance which takes place is not generally so great as in tertiary syphilis. For fiu-ther observations on differential diagnosis, the reader is referred to the article on Syphilis, page 362. Catarrhal ulcerations are nearly always very superficial, so that they have more the character of erosions, and are most common on the vocal cords. ISTon-tubercular itlceration may, of course, supervene in a person suffering from pulmonary phthisis, and such ulcerations may afterwards become tuber- cular through the deposit of tubercles. Prognosis. — The prognosis of laryngeal phtliisis is always extremely nnfavourable, and it is not certain that any cases ever recover. Of all the cases of laryngeal phthisis that I have ever seen, I only know of four in wliich I have reason to beKeve that the disease was entirely arrested. In these instances — in all of which there was deposit in the lungs, and in one a cavity — the laryngeal signs of the disease disappeared, whilst those appertaining to the lungs remained stationary or retrograded. In considering the probable dm-ation of Hfe, the age and family history of the patient, the character and stage of the lung disease, the amoimt and kind of expectoration, the frequency of the pulse, the temperature of the body, the rate at which loss of weight takes place, are the main criteria. These various matters are discussed in detail m the text-books of medicine, and in monographs on phthisis, and it need only be remarked here that, as a nile, patients from eighteen to twenty-five years of age succimib most quickly, and that Avhere there is a strong family predisposition to tuberculosis the fatal issue is sooner reached. Disease withm the larynx is less rapidly fatal than when the morbid process attacks its outer' portions ; in other words, if the epiglottis, or ary- epiglottic folds are infiltrated or ulcerated the disease ter- minates more qmckly than when the ventricular bands or vocal cords are the seat of the disease. This is accounted for by the fact that idceration of the more exposed portions of the larynx interferes most with the act of deglutition, and hence favours marasmus. Ceteris paribus, the greater the amoimt of infiltration the more unfavourable the prognosis ; and in cases in which there are numerous scattered ulcers, without nnich thickening of the mucous membrane, the progi-ess is slower than where there is general infiltration ^ 584 DISEASES OF THE THROAT AND NOSE. The foUowiiig is tke duration of life (in months) after the throat-symptoms had begun to be tronblesonie m 100 cases subjected to post-mortem examination. It wdl be seen that in the greatest nvmiber of cases death occurred m froin twelve to eighteen months, and that 66 per cent occurred between six months and two years. Further, it is to be observed that very few patients kved more than two yeai. -and a half, and very few died before six months :- Table G-. Duration of life after throat-symptoms had become troublesome. No of Cases. Duration of Life in Months. 1 49 2 42 to 48 4 36 to 42 5 30 to 36 13 24 to 30 19 18 to 24 30 12 to 18 17 6 to 12 4 3 to 6 g under 3 Treatment —The constitutional treatment must be the same as that commonly employed in tubercular disease of the lungs Is rec^ards local remedies, the plan aheady recommended for chronic laryngitis sometimes gives relief-the application of Mineral aslingents, by diminishing the -fbihty of he mucous membrane, often quieting the cough. Of these 1 We foimd perchloride of iron (3j. ad gj-) the most service- aUe In the early stages, Dr. Porter i has observed excellent Jesuits feom local apphcations of a solution of sulphate of iron and ammonia. In some cases soothing inha k- Uonrof benzoin or hop act very beneficiaUy. When the couk however, becomes very troublesome no ti-eatment gives s^much relief 'as the insufflation of morphia One-eighth of a trarSiuted with starch should be blown down twice a day fnTas the disease advances the dose shotild be increased to for 1 a grain. It is important to get the arynx^^as far as iSible cleared of the masses of mucus, which often cove it before the powder is introduced; and the patient should ' 1 n?ir Tint to cou-h for a few minutes after the appliea- endeavoui not^o cou,^ treatment reUeves the cough, and ° 1 uTuWaa- Laryngitis." « Trans. Missomi State Med. Assn." 1878. LARYNGEAL PHTHISIS. 385 dentins the patient taking a proper amoimt of food, Iiurnos .on the fatal issue. The fact that the maxumun local anaesthesia is obtained in rather ess than an honr furnishes the indication for the time of administration of the powder in reference to taking food, men there is much a?dema, .scarification affords relief. These are the simple measures .vhich, after trying many plans of treatment, I have been induced to adopt. Other physicians, however, have recom- mended various procedures, some of Avhich _ may be here TBferred to. Thus Dr. Schnitzleri advises msufaation of nitrate of sHver, or acetate of lead dihited with sugar of milk; whilst Dr. Marcet^ recommends, as a local application, a solution of iodme hi ohve oH— twenty grams of lochne with five fn-auis of iodide of potassium hi an ounce of oil, and further advises that this iodized oil should be rubbed into the skm of the neck over the larynx. Dr. Marcet also advises scarification "in the swoUen and mdurated form ■of laryngeal phthisis." Behevmg that the tubercular pro- cess originates in a high state of local vascularity, which is "followed by an abnormal function residing in the tissue and exerted upon the blood," he considers "that by the puncture of the mflamed part, and the consequent relief of the vessels, fresh blood is admitted into the capillaries, and the normal vital force of the tissue is agam caUed into action." In this way he supposes that the morbid process may be tem- porarily arrested; though, of course, the prmiary deposit may continue as a cause of irritation and inflammation. When, however, the mucous membrane is extensivdij infiltrated with -tubercular deposit, Dr. Marcet thinks that scarification should be withlield. Dr. Krishaber^ considers that cauteriza- tion with Vienna paste of the outside of the neck just over the thyroid cartilages, has often heen productive of the best results. He directs that the wound should be kept in a state of suppuration for one or more months. Where the patient can swallow to a slight extent, but experiences difficulty from food occasionally entering the larynx, he should be directed to take thickened liquids. A little aiTowroot, corn flour, or isinglass, may be used for giving a proper consistence to the fluids. By thicltening 1 "Ueber KeHkopfgeschwiire." Wien. Med. Presse. No. 14, ii.f. 1868. 2 " Clinical Notes on Diseases of the Larynx." London, 1869, pp. 9i and 135. ' Loc. cit., p. 673. C Q 386 DISEASES OF THE THROAT AND NOSE. the diink it wUl he much less likely to pass heneath the edges of the epiglottis into the larynx. It is also weU to- du-ect the patient to take the di-ink at a draught— not to sip it This mode of procedure makes the act of deglutition continuous, instead of intermittent, and under these circum- stances the passage of. food into the larynx is much less likely to occur Wlien the patient is unable to swallow at all, life may be often prolonged by feedmg him with the oesophageal tube. As already pointed out, the dysphagia at this stage of the disease is generally due to the act of deolutition being imperfectly performed from non- closm'e°of the larynx by the epiglottis, not to obstruction m the food-tract caused by the thickened epiglottis and arytenoid cartHacres. It is from food " going the wrong way," not from the fact of its being prevented passing down the guUet, that the difficulty m swaUowing arises. Hence there is generaUy very little difficulty in introducmg the esophageal tube (See (Esophageal Instruments.) The fatal termination of phtliisis is, of course, much accelerated if the supply of food is to a gi-eat extent cut off, and I may observe that I have prolonged life for many weeks by giving food and stimulants in the way described. Alcohohc liquids, Avhich the n:rita- bilitv of the throat would not aUow to pass, can be readily introduced into the system by this method. Niitritive enemata can be employed instead of the oesophageal tube, but the results of this method are less satisfactory. If there is much dyspnoea tracheotomy should be per- formed, but the effect of the operation is, as a rule, only ta prolon<^ a miserable existence. I cannot recommend the operation as in any sense curative, and quite agi-ee with Dr SoUs Cohen, who remarks ^ that "it cannot be cui-ative either dh-ectly or indirectly, and is only justifiable to ward off asphyxia from oedema, tWaction, or impaction of necrosed cartilage." It is true that cases have been pub- Shed by Dr. Serkowski^ and Dr. Eipley3which are opposed to this view, but I cannot accept these cases as estabhsliing techeotomy as a curative operation in laryngeal phthisis. S one of S^rkowski's cases the patient sm-viyed the operakon three vears and after death the lungs showed evidence of fai- adv^nld phthisis, but it is highly probable that the tubercu- it affection was developed long after the trachea had been . "Diseases of the Throat." 2npdition New York, 1879, p. 516. 3 " Allgera. Med. Chi. Zeitung." Aug. 1878. ^ Beverley Robinson : Op. cit. PERICHONDRITIS OP THE LARYNX. 387 opened • and in liis other case tliero is no proof that the patient Was really suffering from laryngeid phthisis. In Dr. Ripley's case the operation certainly prolonged the patient s life but was in no sense curative. In opposing tracheotomy in laryngeal phthisis, except when there is urgent dyspnoea, I differ entu'ely from my accomplished pupil Dr. Beverley Eobinson, who observes that in order "to obtain these latter (/■ e favoiu-able results) it seems indicated not to delay the operation, but rather to perform it so soon as the nature of the disease is obvious, and other means appear of no avail." During the last twenty years I have performed tracheotomy in a few cases of laryngeal phthisis— perhaps a dozen— but, although it has often relieved urgent dyspnoea, I cannot recall a single instance in which the operation delayed the pathological process. Far from giving rest to the larynx, the wearing of a canula, in my opinion, tends to irritate the wmdpipe. PEEICHONDEITIS OF THE LAEYNX AND KECEOSIS OF THE CAETILAGES. Latin Eq. — Perichondritis laryngea et ISTecrosis cartilaginum. French Eq. — Perichondrite laryngee et Necrose des cartilages. German Eq. — Entztindung des Perichondriunis des Kehl- kopfs und Necrose des Knorpels. Italian Eq. — Pericondrite della laringee. Necrosi delle car- tilagini. Definition. — Inflammation of the 2^sric7iond7'iu7n of the larynx, and necrosis ( or, more strictly speaJdng, canes ) of the cartilages, the latter being generally dependent on the former. In slight cases the morbid process is no doubt often arrested, slight enlargement of the cartilage remaining, tohilst in syphilis extrusion of a part or lohole of the affected cartilage may take place ; in other cases, however, when an abscess forw.s, hectic fever almost invariably supervenes and death follows. History. — ^This afFection was first described by Honnann ^ in 1 " Von einer in Vereiterung iibergehenden Halsentziinclimg Sammlimff auser- lesener Abhandlungen." Leipzig, 1791. Eyland has been referred to by some authors as having mentioned the subject of the disease of the cartilages of the larynx, but he only describes one case in which dysphagia was said to occur from premattire ossification of the cricoid and arytenoid cartilages. 388 DISEASES OF THE THROAT AND NOSE. 1791 and Albeivsi gave a somewhat fuller account of the disease fifty 'years later, but Rulile first described it in detail. Dittrich,- Pitha,3 and Wilks ^ subsequently reported cases, but it was only when diseases of the larynx began to be investigated with the lai-yiigoscope that any considerable attention was devoted to the subject Since then, cases have been published by Turck,;' Retslag « Soheok.J Gei- hardt,8 Scliroetter,9 myself,!'; and the subject has been treated by Ziemssen" with his usual ability. Etiology —The disease is most common between the ages of twenty and forty, and the fact that it occurs very fre- quently as a sequel to laryngeal phthisis accounts for the crreater incidence of the affection at that period of life. 1 have notes of its occurrence in forty-five autopsies ; hut I have met with it during life in many other cases, especially in phthisis and syphilis. Men are more subject to the disease than women, and in the forty-five autopsies thirty-three ot the subjects were males and twelve females. The following table gives some information as regards the ages of the patients : — FoBTY-pivE Autopsies, In which Necrosis of the Cartilages was present. AGES. From 10 to 20 years 0 20 to 30 ,, 16 30 to 40 „ 11 „ 40 to 50 „ 9 ,, 50 to 60 ,, 5 60 to 70 ,, 4 In three non-fatal cases the disease affected the upper part of the alee of the thyroid cartilage (two the right plate and one the left plate), and there were small external abscesses in Jhe neck I have also seen the disease during life in four cases of cut-throat. In the forty-five autopsies see Patli- olo?v mc^e 391), nineteen occurred in laryngeal phthisis t n^Si ^cafcinonii six in tertiary syphilis, four m typhoid fevei^two in cli^onic laryngitis, and tln-ee were examples of 1 > "American Jour, of Med. Sci." April, 18^8. LOTUS OF THE LAEYNX. 395 S!J,nptoms.-The subjective phenomem of lupus of the in no way chan^^ Z^o^^^ lowSl vl if tL disease advances, there is often con- Xble dysS^ There is usually some hoarseness, and ^^^^o^^eie aphonia. ^^^^ ^^^Ztlf'T^l observed at the same time on some part of the lace, un i™ copic examination the morbid appearances are Sd, but still not of sopecuharakuidas toenable^^^^ observed at once to recognize the disease ; for ^ f ^ « ^^^^^^ points of resemblance to syphilis, cancer, and phtlusis and these three affections must therefore be excluded by a careful investigation of the general condition and history ol the patient. In Tiirck's cases there were ulcers on the epi- glottis with loss of substance, chiefly in the form of a heait- shaped piece eaten out of the middle, as in my case here appended. In several instances gi'owths have been noticed on the anterior surface of the posterior waU of the larynx. These appear as fleshy elevations of variable size, some ot which have an irregular, jagged outline, whilst others are almost spherical. In Lefferts' case the epiglottis was covered with small fleshy tubercles and worm-eaten ulcerations, and in one of my cases (Fig. 85) half the valve was studded with molluscum-like projections. Sometimes the mucous membrane of the pharynx is merely thickened, bub the •greater part of the hard and soft palate and uvula may be covered with reddish fleshy wart-lilve growths, and the pharynx extensively ulcerated. Pa^/io%?/.— According to Virchow the usual anatomical condition found in lupus of the larynx is presented by the follomng description of a case examined by him: An in- durated cicatrix beset by thick knobs as large as a pea, extended from the middle of the dorsum of the tongue deeply down into its roots. The epiglottis was excessively hard, and was bordered by hard warts. From this part the tissues were hardened in a knotty manner as far down as the trachea. The arytenoid cartilages were deeply ulcerated, VirchoVs " Archiv." Bd. xx\'i. p. 44, 1863. - "Diseases of the Throat," p. 272. London, 1864. ^ "Laryngologische Mittheiliingen," ii. p. 84, 1874. Elsberg and Eice : " New York Med. Record," vol. xv. No. 1.. " Loc. cit. 400 DISEASES OP THE THROAT AND NOSE. attains this stage.^ In Yirchow's cases the hase of the ulcerations was formed by indurated tendinous tis ue which penetrated deeply into the surrounding structures. The extraneous graiulation-tissue hears a _c ose resemhlance to the new formations of lupus, and consists mu^roscopically of simple spindle-shaped and stellate connective-tissue cells. B?acti ^division of the cells and nuclei the later-cellular sS) tance soon becomes almost obliterated or absorbed, untd all he normal components of the part disappear The morb d cell infiltration has a considerable proliferative Tarac er the individual cells being round, pale, slightly tanulat easily destructible, and usually possessing a rather f^e ™ulai\ucleus and a nucleolus. The great majority of these cells are superior in size to red blood corpuscles, ^ome attahiing the dimensions of the largest mucous coi- ^""Dtnnosis.-The diagnosis of laryngeal lepra is simple the iuteiS malady never occurring except as a concomitant of the more pronounced forms of general lepra. PromiZis -Th^ prognosis is unfavourable, the laryngeal p JZentoften coLituting only a smaU part of an exten- sive and terrible disease of the cutaneous system. %,:;L.n.-It would be futile, in the 1-sen^^^^^^^^ our knowledge, to discuss any measures for the lacUcal cuje Tth^chsease The various local phenomena must be treated l^rdS to the general rules laid down in the articles on ChronS Laryngitis and (Edema of the Larynx. If the dyspnl is ^gent tracheotomy must be performed. CASES ILLUSTRATING LEPROSY OF THE LARYNX. T • -u+^o-^ tn me bv Mr. Erasmus Wilson, Geox-ge L aged -gMeen sent o m^^by ^ ^^^^ ^^^^^ December 4, 18b5. •^i^^,*'^^"^ ".^^^^i/o- tubercles. The same con- ieet are covered witb ^^'^iij™ ' t^^p^lnis of tbe bauds. Tbe ditiou exists to ,;='^^^,ti°^,d the m^cou^ membrane of the There is no difficulty i^^™Xfweo-ian sailor, from Bergen, whose H. E., aged twenty-seven a ISoiwe , ^^^^^ ^^^^ .ship is in the London Docks, came m ^^^^^^ ^^^^^ '^Jl^T^:^"^^'^^^^ ^-^-^ -^-^ '''''' , Thomas: "Beitr.ge path. Anat. d. Lepra Arab." VirchoWs « Archiv." Bd. Ivii. p. 4oo, 18/^. FRACTURES AND DISLOCATIONS OF THE LARYNX. 401 covered with soft, shining, yeUowish-brown, iiregular, but generally round or oval, tumoui-s, vaiying in si^e from a pea to a marble The ri i and Gurlt Casper's Vierteljahrscluift, 18^1, -Bci. x p , ^T-ul^nales des maladies de ToreiUe," &c. Mars, 1878. FRACTURES AND DISLOCATIONS OP THE LARYNX. 403 lS6o There was a vertical fracture of the thyroid cartilage iu the 1 bbo. inere was a anterior part of the laiynx were median line. TJ^XITSSy ecch^ The two ahe could be not at aU swoUen though «!jS;"7„*'^„/„rodiiced distinct crepitation, easily made to move on each othei and P^^^^^ ^^^^ A laryngoscopic complete aphonia ness of the epiglottis, ^he patient si applied transversely and at dysphagia. btiips 01 g^^^^ , ^^^^ scarified. At across the thyroid cartilage, and tne <^P|6^r:'' |i T)„t the the end of a few days the patient was f t° clrSlac^e had hoarseness remained for six weeks; at that time the caitua^e naa completely united, and there was no trace of a tiactuie. TKe usual symptoms of fractoe of _ the larynx are dyspnoea, cough, expectoration of mucus tinged with blood, and more or less pain and tenderness in the part. Emphy- sema of the neck is also likely to supervene, and m some cases the air may penetrate into the cellular tissue ol the chest and hack, or even further. On manipulation, the broken cartilages ^vill crepitate when the fragments are rubbed against each other, whilst occasionaUy over-ridmg of the fractiu'ed edges gives rise to a perceptible deformity. P/'Oi/rto-s?:*-.— Fractures of the larynx are always attended ivith considerable risk, as the violence wliich occasions them is generally great, and the injury to the soft tissues pro- found. To judge from Henoque's cases, fracture of the cricoid cartUage is an invariably fatal occurrence,- but if tracheotomy be promptly performed some of these cases might probably be saved. Trmtment. —Unless the symptoms are very slight it wUl be advisable to perform tracheotomy as soon as possible, otherwise the patient, although progressing favourably, is not unlikely to perish suddenly on making some slight movement.! Hiiter^ goes so far as to say that "as soon as fracture of the larynx has been diagnosed tracheotomy should be performed, and that even in cases where the diagnosis is not quite certain, the operation should nevertheless be carried out. In no case," he observes, " should the practitioner wait tiU a fit of suffocation comes on, as such an attack may supervene so very suddenly." If the cartilages are much crushed it AviU perhaps be best to lay open the whole length of the larynx, and endeavour to replace the fragments in their proper position. Dr. Panas^ suggests that in some cases Avhere tracheotomy is necessary the fractured portions of the laryn- ' See a case reported by Fredet : " Quelques considerations sur les fractures traumatiques du larynx." Paris, 1865, p. 5. = " Pitha und BiUi-oth's Handbuch." Erlangen, 1871, p. 12. •■• Op. cit. p. 4. 404 DI8E3ASES OF THE THROAT AND NOSE. geal cartilages may be kept in proper apposition and tlie patency of the laryngeal canal preserved, by the introduction of a small hollow india-rubber plug into the larynx from the tracheal opening and its subsequent inflation^ Leeches should be applied to the neck, if there is much ^^^^'^'^^^^ tumefaction ; and ice, both externally and mternally, is some^ times of service. In cases of extreme injury, extirpation of the larynx or resection may have a future. Dislocations of the Larynx.--Tho.e hixations which occur between the larynx and hyoid bone will be referred to in the next section, and here intra-laryngeal dislocations alone ^vill be briefly described. Examples of this condition have been Reported by SicUo ^ and Stoerk.^ In Sidlo's case both the arytenoid cartUages were dislocated forwards and clo^ynwards so that their bodies assumed a horizontal position, ihe dis- location appears to have been the result of the «ontra^^^^^^^^ a syiDhilitic cicatrix on the posterior surface of the cricoid cartUac^e. In Stoerks two cases the left arytenoid cartdage va s in each instance dislocated transversely inwards and Lre was at the same time considerable tumefaction of the ISed cartilage. Both patients --e .-en whose voic had been of a falsetto character from childhood. One case appears to have resulted from cicatricial contraction after dip^Xiia; in the other the etiology was altogether un- ^TL-on of one or both the ventricles is another rare forra of in ilaryngeal dislocation. Of this condition only three muSiationJ3 5n record, and in only one fj^l^^^^^'^^ Dr Lefferts^) was the accident recognized diumg iite. in Se lattefca e both ventricles were prolapsed, ana the left tlie lauer odbe , ■ -jhe accident appears to everted ventricles. > ''Ziemsseii'sCyclopffidia,'\vol. -ni.]3. 968 ^ - Wiener Med. Wochensciift." No. ^0. 1878. ^ Mackenzie: " Growths, etc. p. 34. * "New York Med. Record," June 3, 18/6. FR.VCTURE AND DISLOCATION OF THE HYOID BONE. 405 FRACTURE AND DISLOCATION OF THE HYOID BONE. Latin Eracturai et luxaturaj ossis hyoides. French Fractures et luxations de Tos liyoide. Ge)-7nan iJg.— Eracturen und Verreukungen des Zungen- beins. . . Italim Eratture e lussazioni deU' osso loide. Fradure.—Th.Q hyoid bone is occasionally fractured, and several examples of this injury are on record. The oc- currence, however, is very rare, and no practitioner appears to have encountered more than one case. Gibb ^ has treated the subject almost exhaustively in a monograph based on the consideration of thirteen examples collected from various sources. It appears that the cornua are the only parts of the bone lilcely to be broken, at least in the adult, as in only one of the thkteen cases was the body fractured, the patient being a child aged six years. Of the remaining examples the right cornu was loroken in four, and in live the left. In one case both the greater cornua were fractured, whilst in two the precise natiu-e of the injuries was undetermined. Fracture of the hyoid bone is usually caused by forcible manual compression, as in garrotting, hanging, bow-stringdng, or by direct violence, as by faUs or blows on the neck. The bone may also be fractured by excessive action of the muscles of the part.^ As regards symptoms, there is usually considerable pain in the neck, with inability to turn the head. Extreme odyn- phagia is also commonly present. The voice is generally much affected, and the patient can only speak with pain and etfort, whilst occasionally the injury may produce so much narrowing of the glottis as to threaten death by asphyxia. On examining the tlii'oat the fragments wiU usually be found to be widely separated, and true crepitus is seldom met with. Swelling, ecchymosis, and even lacerations of the mucous membrane of the mouth, are present with more or less frequency. The following case fairly illustrates the accident : — 1 "On Diseases and lujiuies of the Hyoid or Tongue Bone." London, 1862. See also ''Pitha and Billroth's Ai-chiv." vol. iii. " Fracturen des Kehlkopfs." ' See Gibb : Op. cit. 406 DliSEASES OF THE THROAT AND NOSE. In November, 1864, a patient camo to the Hospital for Diseases of the Tliroat, suffering from gi-eat difficulty of breathing also from dysphagia and gi-eat pain in the tlu-oat. The man was^a bncklayeis and the previous day he had faUen about thirty-five feet from the scaffolding of a house. He had cut the nght side of his face and had greatly contused the right shoulder, but he was not aware of any other iniuiy. There was considerable swellmg, and some redness between the .angle of the jaw and the thyroid cartilage on the nght side and on making a careful examination of the neck the nght ieater cornu of the hyoid bone was evidently separated from the body Ke bone The patient was unable to protrude his tongue, as it caused so much pain, and no laryngoscopic examination could be mZT Six leeches were applied over the seat of the mjury, but the Sactxu^ed bone could not be " set," as any attempt to mampulate it Sused very great pain. On the foUowing day the patient was quite Table to Lallow and it became necessary to feed him mth an ^ophageal tube. This procedure had to be candied out for eleven davs when the patient sufficiently, recovered his power of swallowing. Sfthe end of a month from the time of the accident the fracture was ^mpletely united, a superabunda,nt amount of callus havmg been thrown out around the broken ends of the bone. The treatment of fractures of the hyoid hone is sufficiently ohvions on pernsal of the foregoing case Local hlood- lettincr is advisable if there is "much swelhng, whilst rest and silence must be strictly enjoined. Sedatives may be aiven to the patient, and feeding must be carried out, il necessary, by an oesophageal tube. If, however, the passage of the tube causes much pain, the patient must be fed by nutritive enemata. Should symptoms of asphyxia supervene, tracheotomy must at once be resorted to^ but scarification of the interior of the larynx may suffice if there is only slight oedema. K the local mflammation is g r at 1 paLnt^hou^ continuaUy, and ice or cold lotions should be applied to the neck externally. Dislocation.— This is an occasional occurrence, but as the syi^tom are not very obvious, the condition is probably oS overlooked. Gibb ^ has collected several cases, some of which came under his own observation. The causes of he ■ tation appear to be most frequently a relaxation of the muse e and tissues of the part, which aUows of an undue Zt! of motion. The accident -y residt^^^^^^^^^^^^ .train but is more apt to occur when tumours ot tne neck en roach laterally on the hyoid bone. In several of the examples recorded the dislocation seems to have been abnost Sronic in its character, and Hable to continual recurrence throughout the whole of the patient s life. 1 Op. cit. ■WOUNDS OP THE LARYNX. 407 T Inve met witli three cases of dislocation of the hyoid boL of these were caused by the pressure of tumours - one cancerous, the other ymphomatous. The Srd cLe occurred in a clergyman who had he power o nroducing the aifection whenever he desired,! but m whom rat often occurred invohmtarily. In none of these case tet the local symptoms caused ^tTh-n^^^^^^^^^ serious. There was no dysphagia, and only shght hoarseness wHch might have been due to other causes. Severaf preparations in anatomical museums lUustrate displacement of the hyoid bone by humours of the neck such as bronchocele,^- and malignant gro^vths o th« to W pharynx,* and oesophagus.^ In a case brought before the Pathological Society e and reported on by Gibb, a meduUary cancer as large as an orange was situated above and to tHe ricrht of the thyroid cartilage, overlapping its right wing. The body of the hyoid bone was pushed obhquely to the ieli. .ide of the thyroid cartilage, its right horn being much cUsplaced upwards, whilst its left horn rested on the superior border of the thyroid cartilage. , The dislocation can generaUybe easily reduced by throwing the head backwards, relaxing the lower jaw and gently rub- bing the displaced bone. The parts may be snbseqtiently streno-thened by the cold-water douche and stimulating applications. If a generaUy relaxed condition of the tissues throughout the body prevails, suitable tonic and analeptic measures are called for. WOUNDS OF THE LAEYNX. Latin Eq. — Vulnera laryngis. French Eq. — Plaies du larynx. German Eq. — ^Wunden des Kehlkopfs. Italian Eq. — Ferite deUa laringe. Definition. — Incisions, punctures, contused or lacerated wounds of the larynx from tvithout imoards, whether homicidal, suicidal, or accidental. 1 Compare the analogous case of Dr. Ripley, recorded by Gibb (op. cit.). 2 Univ. Col. Hosp. Mus. 550, W. 6. ^ St. George's Hosp. Mus. Catalogue, L. ii. * CoU. Siu'g. Mus. 1095 and 1096. 5 Ibid. 0 "Trans." vol. xii. 408 DISEASES OF THE THROAT AND NOSE. Etiology.— Wownds of the larynx are rare in military surgery, only 6 cases occurring amongst 10,000 wounded.^ In civil practice, however, owing to the frequency with which the part is injured in suicide, the injury is common. Out of 158 cases of cut- throat collected by Durham,^ in 61 the wound was inflicted on the larynx, and 45 were through the thyro-hyoid membrane. In 58 cases analyzed by Horteloup3 30 occurred between the lower margin of the hyoid bone and the upper edge of the first ring of the trachea. According to Malgaigne,* young men, when making suicidal assaults on the throat, as a rule wound themselves above the larynx; whereas in old men the injury is generally inflicted below the cricoid cartilage. The reason of this difference is that old men usually find a difficulty in elevating the clrin and throwing the head well back. Punctured wounds of the larynx are _ generally the result of thrusts made with a bayonet,^ stiletto, or foil, or by some pointed piece of metal or a nail. These punctured wounds are apt to give rise to emphysema of the neck, sometimes causing serious dyspnoea.^ Gunshot wounds are generally of a somewhat contused character, but a bullet will°sometimes pass through the neck leaving only its track in the thyroid cartilage ; or on the other hand it may carry away the greater part of the larynx. A solitary instance is on record in which a buUet fractured the thyroid cartilage without destroying the skin.7 As a rule, the buUet does not remain in the larynx, but if not removed finds its way to the . root of the neck. Four preparations lUustratmg gunshot wounds are to be found in the Army ^ledical Museums in the first instance the baU fractiu'ed the lower jaw, passed through the thyro-hyoid membrane and carried away the epiglottis. In the second the anterior and superior part of the thyroid cartilage was carried away by a buUet, which also fractured the humerus. In the third the baU passed into the larynx- from the side, 1 Witte • ' ' ArcHv. f iir KHnische Chii-urgie,' ' Bd. xxi. Iste C. p. 1 86. ; ?S * "P»"''S69. Se, .is. a valuable Article rPitta-BilS's " H.ndbuoh," vol. m. by Dr. George Fischer : " Wvmden des KeUkopfs. * Horteloupe: Op. cit. p. 17. ft Durham: Op. cit. p. 447. „ v 10,7 Beach: New York Med. Joum." March 1877 ^ George Fischer: "Deutsche Chirui-gie. 18S0, Lief. 34, p. i-J- 8 Nos.°202, 648, 657, 1440. WOUNDS OF THE LARYNX. 409 and wounded the epiglottis. In the fourth and last case the buU^t stuck fast in the upper part of the thyroid cartilage. , , . ■ Symptoms.— Incisions into the larynx (except m the case of surgical operations) are almost invariably transverse. Considerable difference of effect is observed, according as the openin'^ is large or small. In the former case, if the carti- lages are divided entirely tlirough, the Avound gapes widely thi-ough the action of the muscles which elevate and depress the larynx. There is not usually much haemorrhage, but asphyxia may occur rapidly through some part, such as a piece of the epiglottis or one of the arytenoid cartilages, falling into the glottis and blocking it up. In extensive woimds of the larjmx, the voice is usually altogether extinguished. In small wounds or punctures of the larynx the most prominent symptoms are the result of internal haemorrhage and emphysema of the cellular tissue of the neck, chest, or even of the whole body. A clot sometimes quickly forms in the trachea or bronchi, and causes death by suffocation. In aU cases, if the first dangers of the woimd are escaped, subsequent inflammation Avith tumefaction and formation of pus is very likely to place the life of the patient in jeopardy. In illustration I need only refer to the case recorded by Sir C. BeU^ in which a girl plimged a small penknife into her larynx ; some months later exuberant granulations arose which filled up the glottis, and caused death by suffocation. One of the commonest sequelae is the formation of a dense web across the larynx, whilst more or less enlargement of the cartUages, from chronic inflammation, is seldom absent. Occasionally a fistulous aperture leading into the larynx remains after the surrounding parts have healed up, not only shoAving no tendency to spontaneous closure, but resisting all measures except those of a rhinoplastic character. In a case sent to me by Dr. Sutton, of Dover, there Avas an opening as large as a shilling several years after the Avoimd was inflicted. Prognosis. — Out of 88 cases of large wounds 67 patients recovered and 21 died. In 21 instances of small Avoimds there were 10 recoveries and 11 deaths.^ Few patients recover Avithout some modification of the vocal function, but the prognosis in respect to this point depends on the J " Surgical Observations," vol. i. p. 45. - Horteloup : Op. cit. p. 86. 410 DISEASES OF THE THROAT AND NOSE. relation of the incision or puncture to the vocal cords. It will he rememhered that the danger to respiratioiyioes not terminate with the healing of the wound or the rehef of the £rst symptoms. Subsequent cicatricial narrowing of the windpipe may require that the air-passage should he opened, even if that operation was not at first required, or if trache- otomy was performed in the first instance it might either prevent the removal of the tracheal canula, or render tra- cheotomy necessary a second tune. Treatment —The general treatment wiU he discussed under the head of Cut-Throat, it being only necessary to remark here that, in the case of gunshot wounds, or jagged cuts however produced, it is very important to see that any loose fragments of epiglottis, arytenoid cartUage, or mucous membrane, are altogether removed; and that in a punctured wound, any resulting emphysema should be relieved by scarification of the skm. The cicatricial nan-owing of the windpipe, which so often results, must be treated by the mechanical measures described at page 392. Burns of the Larynx.^ Samuel Cooper 2 and Marjolin^ first caUed attention to the frequency of dyspnaa in cases of burn, but it re- mained for Ryland^ to point out that this condifao^ was frequently due to burning flame or higlily heated a^^ Since then Durham ^ and Cohen Miave reported cases. In most of the recorded cases the upper portion of the body was the seat of the burn, but in some mstances the lower Ixtremities alone suffered. The symptoms are generaUy 'SaHain in the throat, difficulty of swal owing, dyspnoea, Shon a and the presence of a quantity of black carbonaceous Ser hr the sputa. The symptoms usually come on a Sw hours after the accident. On examining these case. • " Diet, of Pract. Surg." Art Bma. Trachea," p. 274, 1837. „ ^ - 45(3. gecond edition. 6 "Holmes System 01 burgery, ^" . • „ .1 iotr ti 294 0 Cohen? ''Inhalation, its Therapeutics and Practice. 18/6, p. 294. FOREIGN BODIES IN THE LARYNX. 411 state of acute aulema. There is generaUy great nervous prostration. The prognom is very serious; it depends not only on the extent and depth of the burn but _ a so the age and vigour of the patient must be taken into con- sideration. . . i • , i t. The local treatment should consist m making the patient suck ice and using insufflations of morphia; but if there is much cedema, scarification should be employed, and it neces- sary tracheotomy must be performed. FOREIGN BODIES IE THE LAEYNX. Latin J^Jg.— Corpora adventitia in larynge. French Eq. — Corps etrangers dans le larynx. German Eq. — Fremde Korper im Kehlkopf. Italian Eq. — Corpi stranieri nella laringe. Definition. — Fm-eign bodies generally introduced into the larynx from without, most freqitenthj through the mouth during mastication or deglutition, and only very rarely entering through a woimd in the neck. Occasionally, hoioever,^ they pass upicards from the trachea or oesophagus. Etiology. — A complete collection of all the foreign bodies that at one time or another have found their way into the larynx would probably comprise specimens of every known substance.^ Elesh, bread, fragments of bones of all edible quadi-upeds and fish, stones of various species of fruits, nutshells, grains of corn, peas, beans, shells of moUusks, coins, buttons, pebbles, artificial teeth with their fittings, are examples of the foreign matters that most frequently become impacted in the larynx. The first class of substances, i.e., those connected with alimentary matters, usually gain admission during mastication, whUst the person is laughing or talking; less frequently during the act of deglutition. Eoreign bodies of metallic composition are occasionally impacted in the larynx of children, who amuse themselves by putting coins, buttons, small toys, &c., in the mouth. In rarer instances teeth, real or artificial, or tooth- plates, become loosened during sleep and drawn into the glottis. It is, indeed, very frequently during sleep that the metallic 1 See Gross: "Treatise on Foreign Bodies in the Air-passages. " Philadelphia, 1854. 412 DISEASES OF THE THROAT AND NOSE. bodies mentioned above find admittance into the air-passages in children who have gone to bed with them in their mouths. An accident of this kind occurred to a lad at Wiabeach in the year 1876.1 The boy went to sleep with a toy-engine in his mouth, and during the night it passed into the windpipe. Dr. Bury, who was called to the case, found it necessary to perform' tracheotomy. The cause of the sudden attack of dyspnoea was not knowi at the time, and some months later Dr. Bury sent the patient up to me at the Hospital for Diseases of the Throat, and I transferred the case to my principal clinical assistant. Dr. Samuel Johnson, now of Baltimore. The little engine was found to be so deeply embedded in the sub-glottic region that it could only be extracted after Dr. Johnson had performed thyrotomy. The patient made a complete recovery, though his voice has remained up to the present time (July, 1879), slightly- hoarse. Peas or puff- darts are sometimes sucked in thi-ough tiibes ; and leeches appUed inside the mouth wiU occasionaUy make theu way downwards, though more frequently these animals get into the larynx from drinking dirty water, an accident which has often happened to soldiers on march. Dr. Massei2 succeeded in removing from the pharyngo- laryngeal sinus a living leech which had foimd its way into that situation Avhilst the patient was drinkmg some im- pure river water a fortnight previously. Foreign bodies may also become fixed in the larynx, harmg previously passed upwards through the trachea or oesophagus. A curious case is related by Edwards,^ of a boy eet. eight in whom a bron- chial gland became detached, passed by an ulcerated opening into one of the bronchi, and was thence expeUed up the trachea during violent exertion, so as to become impacted in the rima glottidis. The epiglottis itself niay be drawn into the larynx and become spasmodically fixed m tnat situation. Dr. Solis Cohen* remarks that this accident "usuaUy occurs during eating," but that he has "known it occur during swaUowing of saliya ^f